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THE  LIBRARY 
OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


GIFT 

■.'n.   -i,  Burs  on 


On: 


Ct 


Nervous  and  Mental  Disease  Monograph  Series  No.  i 


OUTLINES 


OF 


PSYCHIATRY 


BY 

WILLIAM  A.  I  WHITE,  M.D. 


SEVENTH   EDITION 


WASHINGTON 

NERVOUS  AND    MENTAL   DISEASE   PUBLISHING 
COMPANY 


1919 


NERVOUS   AND  MENTAL   DISEASE 
MONOGRAPH   SERIES 

Edited  by 
Dt8.  SMITH  ELY  JELLIFFE  and  WM.  A.  WHITE 

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PRESS  OF 

THE  NEW  ERA  PRINTING  COMPANY 

LANCASTER,  PA. 


loo 

J  9/9 


PREFACE  TO  THE  SEVENTH  EDITION. 

The  changes  in  this  edition  have  been  with  the  main  end  in 
view  of  getting  beyond  the  older,  more  static  descriptive  psy- 
chiatry and  carrying  the  student  further  into  the  realm  of  the 
newer,  more  dynamic  interpretative  psychiatry.  I  have  there- 
fore introduced  such  additional  interpretative  formulations  as  are 
consistent  with  the  purposes  of  the  book  as  a  text-book  having  due 
regard  for  a  size  which  I  believe  has  been  an  element  in  its 
success. 

W.  A.  W. 
Saint  Elizabeth's  Hospital, 
Washington,  D.  C, 
January  i,  1919. 


Ill 


Chaftek. 


I. 
II. 
III. 

IV. 

V. 

VI. 

VII. 


VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 


XIX. 
XX. 

XXI. 


CONTENTS. 

Page. 

Preface    iii 

Part  I.    General. 

Descriptive  Psychology    i 

Genetic  Psychology 7 

The  Nature  of  Mental  Disorder ,.  .  13 

Classification  of  the  Mental  Disorders 24 

Causes  of  Mental  Disorders 29 

Treatment   40 

General  Symptomatology  52 

Part  II.     Clinical. 

Paranoia  and  Paranoid  States 87 

Manic-Depressive  Psychoses 112 

Paresis  132 

Dementia  Precox 156 

The  Presenile,  Senile  and  Arteriosclerotic  Psychoses  189 

The  Infection-Exhaustion  Psychoses 209 

The  Toxic  Psychoses 216 

Psychoses  Associated  with  Organic  Diseases  and 

Injury  of  the  Brain 241 

The  Symptomatic  Psychoses  250 

Borderland  and  Episodic  States  255 

Idiocy  and  Imbecility  275 

Part  III.    Methods  of  Examination. 

Principles  and  Methods  of  Examination 283 

A  Minimum  Mental  Examination 317 

The  Binet-Simon  Scale 324 

Index   339 

V 


PART  I 
GENERAL. 


Vll 


OUTLINES  OF  PSYCHIATRY 


CHAPTER   I. 

Descriptive  Psychology. 

Before  undertaking  to  discuss  mental  diseases  it  is  desirable  to 
define  briefly  the  psychological  terms  which  it  will  be  necessary 
to  employ. 

The  body  is  made  up  of  a  great  number  of  organs  each  one 
of  which  has  certain  functions:  The  kidney  to  secrete  urine, 
the  lungs  to  carry  on  respiration,  the  heart  to  force  blood  through 
the  vessels,  the  stomach  and  intestines  to  digest  and  absorb  food. 
Definite  as  is  the  function  of  each  of  these  organs  its  action  must 
be  timed  in  reponse  to  certain  conditions  and  in  relation  to  the 
other  organs  of  the  body  or  it  does  not  serve  its  purpose  in  the 
individual  economy.  The  stomach  must  secrete  its  juices  when 
food  is  introduced,  the  bladder  contract  when  urine  is  to  be 
expelled,  the  active  brain  must  be  supplied  with  an  increased 
amount  of  blood,  the  kidneys  and  the  skin  must  act  harmoniously 
together  to  excrete  certain  substances,  the  respirations  increase 
on  physical  exertion  and  so  on  indefinitely.  It  is  the  function 
of  the  nervous  system  to  so  organize  the  activities  of  the  several 
organs  that  they  are  rightly  timed  and  properly  adjusted  in  rela- 
tion one  to  another.  This  is  the  main  function  of  the  simpler 
reflex  arcs,  chiefly  belonging  to  the  vegetative  nervous  system, 
the  spinal  cord  and  medulla. 

The  upper  cerebral  pathways  of  the  cortex  that  constitute  the 
physical  basis  of  mind  have  quite  a  different  series  of  functions. 
These  functions  are  so  to  regulate  and  control  the  actions  of  the 
individal  as  to  best  serve  his  interests  in  his  relations  with  his 
environment. 

In  order  to  do  this  the  cerebral  cortex  must  be  brought  into 
relation  with  the  environment  through  the  sense  organs,  these 


2  OUTLINES   OF  PSYCHIATRY. 

relations  must  be  coordinated  and  the  resultant  functioning  is 
designated  as  conduct.  To  illustrate:  A  man  standing  in  the 
middle  of  the  street  sees  a  runaway  team  dashing  towards  him. 
His  sensory  pathways,  figuratively  speaking,  carry  to  his  mind  the 
information  of  the  presence  of  the  runaway  team,  its  distance 
from  him,  the  distance  to  the  sidewalk  from  where  he  stands  and 
many  other  things.  His  mind  assimilates  all  these  facts  and  by  a 
process  of  reasoning  the  conclusion  is  reached  that  safety  lies  in 
his  immediately  gaining  the  sidewalk  which  is  in  front  of  him. 
The  necessary  volitional  processes  are  initiated  and  thus  the  ac- 
tions of  the  individual  are  so  related  to  the  conditions  in  his  en- 
vironment as  to  conserve  his  best  interests :  in  this  case  to  save 
his  life. 

In  order  that  the  adjustment  of  the  individual  to  his  environ- 
ment could  take  place  three  things  were  necessary:  (i)  Experi- 
ence of  the  environment  must  be  gained.  (2)  This  experience 
must  be  organized,  associated  and  brought  into  relation  with 
previous  experiences.  (3)  It  must  be  transformed  into  the  ap- 
propriate actions.  The  first  of  these  functions  is  made  possible 
by  the  group  of  sensory  receptors  and  their  pathways  to  the 
cortex.  These  collectively  may  be  called  the  sensorium.  The 
second  function  organizes  the  experiences,  and  the  resultant  func- 
tion may  be  called  the  intellect.  The  third  discharges  the  energy 
brought  in  through  the  sensory  pathways,  arranged  and  coordi- 
nated for  purposeful  activities,  through  motion  or  glandular  ac- 
tivity. These  are  collected  functions  of  what  may  be  termed  the 
motorinm.  In  the  language  of  the  psychology  which  considers 
each  of  them  as  faculties  of  the  mind  the  function  of  the  sensorium 
is  perception,  of  the  intellect  thinking,  and  of  the  motorium 
volition.     (See  Fig.  i.) 

With  this  view  of  the  function  of  consciousness  as  a  guide  the 
separate  processes  may  now  be  described  more  in  detail. 

As  has  been  seen  all  the  information  of  the  environment  must 
come  through  the  sense  organs ;  it  follows  of  necessity  that  sensa- 
tions play  an  important  part  in  making  up  the  content  of  con- 
sciousness. These  sensations  are  the  result  of  the  stimulation  of 
the  specialized  sensory  end  organs,  and  from  the  view-point  of 
descriptive  psychology  comprise  the  unanalyzable  material  out  of 
which   mental    functioning   is   composed.     Light  energy  coming 


DESCRIPTIVE   PSYCHOLOGY.  3 

through  the  eye  gives  the  sensations  of  light  of  different  colors 
and  intensities,  the  ear  sensations  of  sound  of  varying  quaUties 
and  loudness  and  so  on  in  each  sensory  realm,  the  sensations  re- 
ceived being  variable  both  qualitatively  and  quantitatively.  Some 
two  dozen  or  more  sensory  receptors  are  known,  each  responding 
to  specific  types  of  stimuli.^ 

If  we  will  stop  and  consider  for  a  moment,  however,  it  will 


SEMSORIUM 
PERCEPTION 


INTELLECT 
THINKING 


MOTORIUM 
VOLITION 


z*- 


Fig.  I.  a,  a^,  a^,  a^,  a*,  represents  the  afferent  peripheral  nervous  sys- 
tem, the  avenues  for  conveying  sensory  impulses,  z,  c^,  s^,  z^,  2*,  repre- 
sents the  efferent  peripheral  nervous  system,  the  avenues  through  which 
motor  responses  travel. 


at  once  be  seen  that  these  elemental  sense  experiences,  like  atoms, 
cannot  exist  alone  and  uncombined :  That  sensations  of  light, 
sound,  pain,  coldness,  can  never  as  such  go  to  make  up  a  conscious 
state.  In  front  of  me  as  I  write  is  something  which  produces  the 
sensation  of  a  variously  shaded,  round  patch  of  yellow,  but  even 
while  looking  at  it  I  know  much  more  of  it  than  simply  that  it  is  a 
patch  of  yellow :  I  recognize  it  as  an  orange.  What  has  been 
added  to  the  visual  sensations  of  roundness  and  yellowness  to 
produce  this  result  ?  Just  this.  Many  times  in  the  past  the  same 
sort  of  light  stimuli  have  caused  sensations  of  roundness  and 
yellowness  and  many  times  in  connection  with  these  sensations 
other  kinds  of  stimuli  have  caused  touch,  taste,  and  smell  experi- 

^  Herrick,  C.  Judson :  An  Introduction  to  Neurology,  Philadelphia,  W. 
B.  Saunders  Company,  1915. 


4  OUTLINES   OF  PSYCHIATRY. 

ences  and  this  combination  I  have  learned  to  call  orange.  So 
when  the  sensations  of  roundness  and  yellowness  are  received 
they  are  associated  in  the  brain  with  those  other  sensory  elements 
of  touch,  taste,  and  smell,  which  have  occurred  before.  The  as- 
sociation of  the  previous  with  the  present  sensory  elements  causes 
me  to  recognize  the  round  patch  of  yellow — not  solely  as  a  patch 
of  yellow — but  as  an  orange.  To  this  process  of  forming  a  mental 
image  of  an  object  presented  to  the  senses  is  given  the  name 
perception. 

It  is  this  process  of  perception  which  furnishes  to  the  individual 
the  knowledge  of  his  environment  which  by  association  with  the 
knowledge  gained  in  the  past  leads  to  appropriote  actions.  This 
process  of  association  is  an  association  with  ideas  which  may  be 
said  to  be  images  of  objects  formed  in  the  mind  but  not  presented 
to  the  senses  at  the  time.  The  only  difference  then  between 
percepts  and  ideas  is  the  presence  in  the  former  of  sensory 
elements. 

The  process  of  the  relation  of  percept  to  ideas  and  the  associa- 
tion of  ideas  one  with  another  or  in  general  terms  this  process 
of  the  assimilation  and  rearrangement  of  the  materials  of  knowl- 
edge furnished  by  the  senses  with  the  materials  already  present 
in  consciousness  is  the  process  of  thinking.  When  from  the  as- 
sociation of  two  or  more  ideas  there  issues  forth  a  new  and  dif- 
ferent idea  the  process  which  produces  this  result  is  the  process 
of  reasoning  and  the  new  idea  is  termed  a  judgment. 

Having  obtained  experience  of  the  environment,  the  process  of 
perception,  and  having  assimilated  the  various  percepts,  reasoned 
regarding  them  and  reached  certain  judgments,  the  next  step  in 
the  order  of  events  is  the  release  of  appropriate  actions.  If  the 
reasoning  is  at  all  complicated  there  are  usually  several  judgments 
formed,  each  one  of  which  may  tend  to  express  itself  in  an  ap- 
propriate action,  the  strongest  one  finally,  however,  succeeding 
in  expressing  itself.  This  conflict  of  tendencies  has  been  de- 
scribed as  the  "battle  of  motives"  by  Ziehen  who  gives  the  fol- 
lowing illustration: 

"I  see  a  rose  in  a  strange  garden  (stimulus  and  sensation). 
A  long  series  of  ideas  is  aroused  by  the  stimulus  and  the  visual 
sensation  of  the  flower  (idea-association).  For  instance,  the 
memory  of  the  rose's  fragrance  comes  to  mind,  then  I  think  how 


DESCRIPTIVE   PSYCHOLOGY.  5 

well  it  would  look  in  my  room,  that  it  is  the  property  of  another, 
that  plucking  it  would  be  punishable,  and  so  on.  Only  after  the 
whole  series  of  presentations  has  passed  before  the  mind  does 
action  follow,  and  whether  I  pluck  the  flower  or  go  my  way 
without  it  will  depend  upon  the  strength  and  intensity  of  the  con- 
quering idea." 

The  conscious  realization  in  action  of  the  strongest  motive  is 
the  process  of  volition  and  is  accompanied  by  a  feeling  of  freedom 
to  choose  which  motive  shall  dominate.  The  sum  total  of  the 
actions  of  the  individual  is  known  as  conduct. 

All  of  these  various  processes  which  have  been  described  must 
of  course  be  conceived  of  as  taking  place  in  conjunction  with 
certain  physiological  processes  in  the  cells  and  fibers  of  the  cere- 
bral cortex.  These  physiological  processes,  here  as  elsewhere, 
involve  changes  in  the  energy  and  the  material  substance  of  cells 
and  fibers  and  so  when  a  certain  mental  process  has  occurred 
once  accompanied  by  its  correlative  physiological  process  the 
changes  in  nerve  cells  and  fibers  will  have  left  such  an  impress 
that  a  subsequent  process  of  this  sort  will  occur  more  readily. 
In  other  words  a  mental  process  having  once  occurKed  tends  to 
recur  in  the  same  way  when  the  same  conditions  are  repeated. 
This  tendency  is  the  physiological  basis  of  conscious  memory, 
which  psychologically  may  be  said  to  be  the  recurrence  to  con- 
sciousness of  a  previous  experience  and  the  recognition  of  it  as 
having  occurred  before. 

All  mental  processes,  besides  these  special  qualities  which  char- 
acterize them,  are  accompanied  by  certain  general  conditions  of 
consciousness  known  as  affects  which  are  pleasant  or  unpleasant, 
pleasurable  or  painful,  agreeable  or  disagreeable,  and  like  sensa- 
tions are  unanalyzable,  elemental  constituents  of  consciousness. 
These  pleasurable  or  painful  conscious  states  arise  as  the  result 
of  the  interaction  between  the  individual  and  the  environment 
and  are  known  as  feelings  when  this  interaction  is  relatively 
simple  and  direct,  i.  e.,  a  shrill  whistle  may  be  accompanied  by  a 
feeling  that  is  disagreeable  to  the  point  of  being  actually  painful. 
When  the  interaction  is  relatively  more  complex  and  indirect 
there  may  result  the  state  of  consciousness  known  as  an  emotion, 
i.  e.,  the  bell  of  a  locomotive  and  the  hiss  of  an  air  brake  is  heard 
coupled  with  screams  and  cries  of  pain.     The  mind  at  once  pic- 


b  OUTLINES   OF  PSYCHIATRY. 

tures  to  itself  an  accident  and  the  emotion  of  fear  arises  in  con- 
sciousness. If  the  interactions  are  still  more  complex  and  indi- 
rect the  resultant  phenomena  are  termed  sentiments,  such  as 
honor,  patriotism,  etc. 

An  intense  emotion  of  relatively  short  duration  is  spoken  of  as 
a  passion,  such  as  anger,  terror,  revenge,  despair,  triumph.  A 
moderate  emotion  of  relatively  long  duration  is  spoken  of  as  a 
mood,  such  as  despondent,  optimistic,  contented,  blaseness.  When 
the  mood  is  continuous  and  dominates  the  personality  it  becomes 
the  quality  which  is  called  temperament.  Thus  we  speak  of  san- 
guine, pessimistic,  suspicious  temperaments. 

From-  this  description  of  mental  functions  it  will  be  seen  that 
they  are  most  intimately  connected,  in  fact  they  are  not  separate 
and  distinct  in  any  sense,  but  only  parts  of  a  large  whole.  The 
old  psychology  conceived  of  mind  as  composed  of  a  number  of 
cubby  holes  in  each  one  of  which  was  pigeon-holed  a  special 
faculty,  feeling,  thinking,  volition,  each  one  of  which  was  quite 
as  distinct  from  the  others  as  this  illustration  implies.  This  con- 
ception has  become  inadequate  and  false.  The  "  faculty  con- 
cepts "^  are  conceived  of  as  what  they  really  are,  "  class  designa- 
tion of  certain  departments  of  the  inner  experience,"  and  not 
"  forces,  by  whose  means  the  various  phenomena  are  produced." 
"  Objectively,  the  individual  mental  processes  can  be  regarded 
only  as  inseparable  elements  of  interconnected  wholes."  Mental 
processes,  from  their  incidence  in  sensations  to  the  release  of  the 
motor  responses  constituting  conduct  are  conceived  to  have  as 
their  physical  substratum  a  continuous  neural  process.  The 
process,  although  differently  named  in  different  parts  of  its  course 
for  convenience  of  designation,  is  a  continuous  one. 

2  Wundt,  Wilhelm :  Principles  of  Physiological  Psychology.  Translated 
by  Edward  Bradford  Titchener,  Vol.  I.  New  York,  The  Macmillan  Co., 
1904. 


CHAPTER   II. 

Genetic  Psychology. 

In  the  last  chapter  a  number  of  psychological  terms  such  as 
sensation,  perception,  emotion,  etc.,  were  defined.  Not  so  many 
years  ago  psychology  occupied  itself  largely  in  efforts  to  formulate 
more  or  less  refined  definitions  of  such  terms.  Those  were  the 
days  when  text  books  of  psychology  were  written  in  the  library 
with  little  or  no  first  hand  knowledge.  In  later  years,  however, 
owing  largely  to  the  necessity  for  the  development  of  objective 
methods  by  the  animal  psychologists,  because  animals  cannot  tell 
what  is  going  on  in  their  minds,  psychological  problems  have  been 
reduced  to  problems  of  behavior.  That  is,  instead  of  manu- 
facturing hair  splitting  definitions  of  what  constitutes  a  sensation 
the  psychologists  try  to  answer  the  question  "  What  is  the  person 
doing?"  or  leastwise,  trying  to  do. 

From  this  behavioristic  stand-point  a  proper  description  of  my 
conduct  at  the  present  time  would  be  included  in  the  statement 
that  "I  am  writing  a  book"  rather  than  in  a  statement  of  the 
particular  sensations,  perceptions,  and  volitions  which  are  taking 
place  in  me. 

A  still  further  implication  of  this  way  of  looking  at  psychic 
facts  is  that  I  am  writing  a  book  because,  of  all  the  motives  for 
conduct  that  may  be  seeking  expression  at  this  particular  moment, 
that  is  the  strongest.  In  other  words  I  "  wish  "  to  write  a  book 
and  so  the  "  wish  "  has  replaced  the  "  sensation  "  as  the  ultimate 
psychological  unit. 

If  now  it  be  further  asked  Why  I  wish  to  write  a  book?  that 
question  can  only  be  answered  by  an  examination  of  my  past  such 
as  will  reveal  the  elements  therein  which  have  led  to  this  particular 
conduct.  Such  an  examination  alone  will  give  the  explanation  of 
my  conduct  by  furnishing  the  chain  of  causes  back  of  it  and  such 
a  study  in  the  psychological  realm  is  a  study  in  genetic  psychology. 

Genetic  psychology  gives  the  same  value  to  mind  that  anatomy 
and  physiology  do  to  the  body  and  like  them  recognizes  that 

7 


8  OUTLINES   OF   PSYCHIATRY. 

present  forms  can  only  be  explained  by  the  past.  In  other  words 
the  mind  has  a  history  just  as  the  body  has :  it  has  its  embryology 
and  its  comparative  anatomy,  and  a  study  of  the  development  of 
the  mind  in  the  individual,  and  its  degree  of  development,  like- 
nesses and  differences  in  different  races  throws  the  same  sort  of 
light  upon  psychological  facts  as  does  the  study  of  embryology 
and  comparative  anatomy  upon  the  facts  of  anatomy  and 
physiology. 

I  will  very  briefly  outline  the  most  important  feature  for  our 
purposes  in  the  developmental  history  of  the  individual  at  the 
psychological  level. 

I  will  begin  with  the  baby  in  its  mother's  uterus.  The  state  of 
mind,  if  the  word  mind  can  properly  be  used  here  as  meaning  the 
resultants  of  all  those  tendencies  which  involve  the  individual  as 
a  whole,  may  be  properly  described  as  one  of  unconditioned 
omnipotence.^  Every  function,  eating,  breathing,  etc.,  being  per- 
formed for  it  by  its  mother  no  desires  can  arise  because  every- 
thing is  furnished  before  a  need  for  it  is  permitted  to  exist.  With 
every  wish  gratified  it  is  therefore  in  a  position  of  omnipotence. 
All  this  is  changed,  however,  at  the  moment  of  birth.  From  this 
time  forth  the  baby  must  eat  for  itself,  breathe  for  itself  and 
perform  many  other  functions  for  itself.  From  now  on  desire 
begins  to  play  a  large  part  in  the  baby's  psychology.  If  dinner  is 
delayed  the  baby  is  hungry  and  by  that  fact  alone  its  omnipotence 
is  imperiled.  The  household,  however,  is  all  intent  upon  serving 
the  baby  and  the  cry  of  hunger  is  immediately  quieted  by  giving 
it  food,  but  as  the  days  go  on,  as  the  sense  organs  develop  and  its 
relations  to  the  environment  require  more  and  more  complex  ad- 
justments no  amount  of  watchfulness  on  the  part  of  the  family 
can  forestall  all  of  its  desires.  Food  is  not  available  the  instant 
it  is  wanted,  light  and  sound  invade  at  times  of  fatigue,  and  so 
desire  comes  more  and  more  into  evidence. 

The  discrepancy  between  desire  and  attainment  is,  however,  not 
very  great  because  all  through  the  first  months  and  even  years  the 
family  try  to  provide  for  all  of  the  child's  needs,  but  the  dis- 
crepancy tends  constantly  to  increase  as  the  years  go  on  and  as 
the  growing  individual  comes  to  touch  reality  at  more  and  more 

^  Ferenczi,  C. :  Contribution  to  Psycho-Analysis.  Boston,  Richard 
Badger. 


GENETIC   PSYCHOLOGY.  g 

numerous  points.  This  lack  of  satisfaction,  desire,  or  wish  is 
thus  the  motive  force  behind  conduct  forcing  the  individual  along 
the  path  that  will  bring  an  end  to  the  craving.  As  desire,  through 
the  years,  becomes  more  and  more  ambitious  and  its  satisfaction 
more  and  more  difficult,  that  satisfaction  has  to  be  postponed  to  an 
ever  receding  future.  As  an  adult  if  he  is  hungry  he  cannot  get 
food  by  just  wishing  for  it  as  he  did  when  a  baby,  but  must  buy 
it  and  in  order  to  do  this  must  earn  money  and  all  the  activities 
implied  in  these  two  statements  must  be  pursued  along  lines  laid 
down  by  social  custom. 

This  discrepancy  between  desire  and  attainment  leads  to  con- 
duct which  has  the  object  of  neutralizing  the  desire  but  with  each 
success  new  desires  arise  so  that  final  success  is  impossible.  This 
conflict  between  desire  and  attainment  is  at  the  very  basis  of 
mental  life  and  the  fundamental  fact  of  consciousness. 

Confronted  by  the  problem  presented  by  the  discrepancy  be- 
tween desire  and  attainment  the  individual  may  seek  the  solution 
in  one  of  two  ways.  He  may  undertake  to  do  the  various  things 
which  will  bring  about  a  satisfaction  of  his  desire  or  he  may 
phantasy  that  it  is  satisfied.  In  the  first  case  the  thinking  which 
controls  his  action  is  dominated  by  the  reality  motive,  that  is,  it 
is  a  clearly  conscious  voluntary  effort  at  efficient  action.  The 
thinking  which  controls  the  dreaming  is  dominated  by  the  pleasure- 
pain  motive  which  shrinks  from  the  effort  necessary  to  action  and 
escapes  it  by  wish-fulfilling  phantasies.  Thus  the  individual  re- 
tains the  ability  to  immediately  satisfy  any  desire  as  he  could 
when  an  infant.  Growing  up,  however,  involves  the  relinguish- 
ment  of  immediate  satisfaction,  or  more  technically  its  repression 
and  the  substitution  of  a  more  complicated  procedure.  Instead 
of  the  sequence  hunger-food  there  comes  about  the  sequence 
hunger- work-money- food. 

This  process  of  repression  is  constantly  crowding  material  into 
the  unconscious,  that  region  which  constitutes  the  historical  past 
of  the  psyche,  the  region  of  methods  of  reaction  which  have  been 
abandoned  for  something  better  as  development  proceeded.-  This 
region  of  the  unconscious  is  of  great  importance  to  psychiatry 

-  For  a  fuller  discussion  of  these  mechanisms  see  the  author's  "  Mech- 
anisms of  Character  Formation,"  New  York,  The  Macmillan  Company, 
1916. 


lO  OUTLINES   OF  PSYCHIATRY. 

because  out  of  it  come  the  motives  for  conduct  which  is  so  gro- 
tesque as  to  be  described  as  unpsychological  because  the  motives 
are  those  which  have  been  so  long  since  abandoned  as  conscious 
causes  of  conduct  and  when  they  arise  from  the  unconscious  are 
not  recognized. 

At  the  psychological  level  we  can  recognize  as  this  process  of 
development  is  going  on  with  its  conflicts,  repressions,  and  the 
ever  increasing  realm  of  the  unconscious,  two  fundamental  and 
controlling  groups  of  desires.  The  one  group  which  has  as  its 
goal  self-preservation  and  of  which  hunger  is  the  type,  and  the 
other  group  which  has  as  its  goal  race-preservation  and  of  which 
the  sexual  relation  is  the  type.  The  energy  which  drives  to  these 
two  goals  may  be  termed  the  libido,  that  component  which  drives 
toward  the  self-preservation  goal  would  then  be  the  nutritive 
libido  and  that  component  which  drives  towards  the  race-pre- 
servative goal  would  be  the  sexual  libido.  Self-preservation  and 
race-preservation  are  in  fundamental  conflict.  The  first  implies 
keeping,  the  second  giving.  To  bring  up  children  involves  cer- 
tain sacrifices  which  the  selfish  are  not  equal  to  and  so  we  see 
here  one  of  the  essential  conflicts  which  he  at  the  basis  of  mental 
life. 

One  of  the  earliest  problems  presented  by  this  conflict  with 
which  the  infant  must  busy  itself  is  learning  to  distinguish  itself 
from  the  environment.  The  infant  has  no  way  of  knowing  that 
that  thing  out  there  is  its  foot  and  is  an  integral  part  of  its  body. 
This  is  well  shown  by  the  fact  that  it  is  at  first  treated  just  like 
anything  else,  the  rubber  ball  for  example.  It  is  picked  up  and 
put  in  the  mouth.  It  takes  a  long  series  of  experiments  to  effect 
this  distinction  between  the  "  I "  and  the  "  not-I,"  a  series  in 
which  numerous  painful  contacts  with  the  objects  surrounding  it 
play  a  considerable  part.  In  the  course  of  learning  this  distinc- 
tion, however,  there  goes  along  a  tendency  to  give  personal  quali- 
ties— its  own — to  every  object  until  experiment  proves  this  un- 
warrented — and  so  the  child's  interest  is  led  from  object  to 
object,  from  person  to  person,  in  a  manner  that  makes  for  an 
ever  increasing  knowledge  of  the  environment,  objective  and 
personal. 

This  drafting  of  interest — the  libido — first  in  one  direction 
and  then  in  another  is  characteristic  of  the  young.     As  the  years 


GENETIC  PSYCHOLOGY.  1 1 

go  by,  however,  the  interest  tends  to  become  confined  to  more  and 
more  definite  directions  and  objects  and  it  is  this  restriction  of  the 
possibilities  which  is  the  fundamental  characteristic  of  old  age. 

The  most  important  of  the  objects  which  arrest  the  attention  of 
the  infant's  libido  are  the  parents.  The  interest,  libido,  or  we 
may  say  the  love  of  the  infant  goes  out  at  first  indifferently  to  the 
individuals  in  its  immediate  environment  and  of  course  the  first 
ones  to  attract  it  are  the  parents,  or  if  one  or  both  are  dead  or 
physically  absent  then  those  persons  who  occupy  their  places  in 
the  care  of  the  infant.  This  is  important  because  it  depends 
upon  the  first  experiences  of  love  and  affection,  the  original  set, 
so  to  speak,  how  all  future  love  experiences  will  be  shaped.  The 
father  and  mother  stand  as  types  in  the  infant  mind  against  which 
all  other  persons  with  which  it  comes  in  contact  later  are  measured 
and  compared.  Not  only  this,  but  as  the  father  and  mother  are 
male  and  female  the  child's  earliest  attractions  tend  to  a  differ- 
entiation based  upon  sex.  The  detachment  of  the  libido  from 
one  person  and  its  attachment  to  another,  its  drafting  from  one 
love  object  (person)  to  those  throughout  life  always  remains 
conditioned  by  the  nature  of  its  first  attachment. 

This  determination  of  the  libido  first  in  one  direction  then  in 
another,  its  deflection  by  new  objects  of  interest  follows  a  more 
or  less  definite  course,  with  of  course  individual  variations,  and  in 
its  various  tendencies  is  guided  by  the  pleasure-pain  motive,  that 
is,  it  goes  in  the  direction  of  pleasure  and  away  from  pain. 

At  first,  particularly  when  the  infant  is  engaged  in  dififerentiat- 
ing  itself  from  its  environment,  it  is  self -centered — auto-erotic — 
the  interest  is  concentrated  in  its  own  sensations.  Later  when  it 
begins  to  be  capable  of  direction  upon  outside  objects  these  ob- 
jects are  given  its  own  characteristics,  they  are  personified,  a 
tendency  which  is  given  full  play  in  the  doll  period.  Later  still 
this  tendency  to  personification  sinks  into  the  background  but 
perhaps  is  never  wholly  given  up,  at  least  it  comes  to  the  fore 
prominently  in  the  state  of  intoxication  or  of  anger,  when  the 
individual  will  break  furniture,  dishes,  etc.,  as  an  expression  of 
his  feelings. 

With  regard  to  the  personal  attachments  of  the  libido  the  same 
general  course  is  pursued,  namely  from  self  outward  into  the 
world  of  reahty.     The  child's  first  interest  is  in  itself,  then  in  other 


12  OUTLINES   OF  PSYCHIATRY. 

children  most  like  itself — narcissistn — and  therefore  of  the  same 
sex — homosexual.  Gradually  the  interest  becomes  capable  of 
attachment  to  persons  less  and  less  like  itself,  that  is  of  the  oppo- 
site sex,  and  the  foundation  is  laid  for  the  specific  activities  of 
race-preservation,  sexual  congress,  care  and  rearing  of  children, 
organization  of  the  home,  etc. 

This  very  briefly  is  an  account  of  the  more  important  occupa- 
tions of  the  libido  which  have  to  be  borne  in  mind  in  the  interpre- 
tative evaluation  of  psychological  facts,  and  the  understanding  of 
the  psychoses. 

During  this  period  of  the  wandering  of  the  libido,  its  fixation 
upon  love  objects  of  greater  and  greater  social  value,  the  individual 
gradually  learns  to  give  up  trying  to  bring  things  about  by  phan- 
tasy, to  make  things  come  true  by  thinking  them  true  (the  all- 
pozverfulness  of  thought)  which  once  worked  when  he  was  an 
infant,  and  comes  more  and  more  to  be  controlled  by  the  reality 
motive  for  conduct — the  seeing  of  things  as  they  are  rather  than 
as  they  are  wished  to  be. 


CHAPTER  III. 

The  Nature  of  Mental  Disorder, 

It  will  be  well  at  this  point  to  dilate  somewhat  upon  the  general 
mental  mechanisms  outlined  thus  far  with  a  view  to  gaining  some 
insight  into  their  nature.  The  results  of  mental  functioning,  in 
the  most  general  terms,  is  to  adapt  the  individual  to  his  environ- 
ment. It  may  therefore  be  considered  as  an  adaptive  mechanism. 
Bearing  this  characterization  in  mind  we  can  best  approach  our 
subject  by  drawing  a  comparison  between  the  problems  of  the 
internist  on  the  one  hand  and  the  psychiatrist  on  the  other.  This 
comparison  is  very  well  put  by  Mercier  :^ 

"When  the  student  of  medicine  passes  to  the  study  of  insanity, 
he  crosses  a  scientific  frontier,  and  enters  an  entirely  new  province 
of  knowledge.  Hitherto  his  purview  has  been  limited  to  the 
processes  that  go  on  within  the  body  and  whatever  references 
he  had  to  make  beyond  that  field  were  indirect  and  of  secondary 
import.  He  needs  to  know  the  structure  and  functions  of  the 
several  organs  of  the  body,  and,  when  any  function  is  disordered, 
his  calling  is  to  take  measures  to  readjust  the  bodily  processes  to 
one  another  so  that  they  may  work  in  harmony  again.  He  has, 
in  short,  to  maintain  the  organism  in  a  fit  state  to  do  its  work, 
whatever  that  may  be,  but  with  the  doing  of  the  work  he  has  no 
concern.  What  the  work  may  be,  and  with  what  efficiency  it  may 
be  performed,  is  no  concern  of  his,  except  in  so  far  as  these 
things  may  affect  the  general  capacity  of  the  organism  to  con- 
tinue its  existence.  His  position  towards  the  patient  is  the  posi- 
ticn  of  the  shipwright  and  the  engineer  towards  the  vessel  on  which 
they  are  engaged.  Like  them,  he  must  be  thoroughly  acquainted 
with  the  structure  and  function  of  every  part,  and,  like  them,  he 
must  be  upon  the  watch  to  repair  the  structure  and  correct  the 
function,  when  the  one  is  damaged  or  the  other  is  at  fault;  but 
with  the  ship's  course  he  has  nothing  to  do.     That  is  a  matter 

1  Mercier,  Charles:  A  Text-Book  of  Insanity.  New  York,  The  Mac- 
millan  Co.,  1902. 

13 


14  OUTLINES    OF   PSYCHIATRY. 

altogether  beyond  his  province.  When  the  student  oversteps  the 
bounds  of  medicine  to  enter  upon  the  study  of  insanity  he  leaves 
the  engine-room  for  the  quarter-deck.  He  is  no  longer  directly 
concerned  with  the  integrity  of  the  structure  or  the  efficiency  of 
the  engines.  His  function  now  is  to  set  the  ship's  course,  to  note 
the  way  in  which  she  comports  herself  in  wind  and  weather,  to 
study  charts  and  tides,  stars  and  clouds,  to  watch  the  barometer 
and  to  sound  the  lead,  and  generally  to  relinquish  the  observation 
of  the  ship  herself,  and  to  take  up  that  of  her  relation  to  the  world 
in  which  she  moves.  This  is  the  function  of  the  student  of  in- 
sanity— to  study  the  individual,  not  per  se,  or  simpUciter,  but  in 
relation  to  the  world  in  which  he  exists,  and  in  which  he  has  to 
maintain  his  existence." 

This  illustration  shows  admirably  the  two  different  view-points. 
Like  most  such  distinctions,  however,  the  two  positions  must  not 
be  considered  as  mutually  exclusive.  It  is  true  that  the  navigator 
is  not  primarily  interested  in  the  condition  of  the  machinery  yet 
if  a  break-down  occurs  he  cannot  direct  the  ship.  Similarly  the 
engineer  is  not  primarily  interested  in  the  course  of  the  ship  yet 
if  she  go  upon  the  rocks  his  machinery  may  be  hopelessly  smashed. 
And  so  with  the  internist  and  psychiatrist.  The  psychiatrist  is 
not  primarily  interested  in  the  condition  of  the  several  organs 
yet  an  uremia  from  Bright's  disease  will  produce  most  profound 
mental  symptoms.  The  internist  is  not  primarily  interested  in 
the  mental  adaptations  yet  they  may  fail  so  hopelessly  as  to  pro- 
duce organic  disease. 

The  influence  of  the  state  of  the  different  organs,  particularly 
when  diseased,  upon  mental  functioning  is  a  commonplace,  while 
Pawlow^  and  Cannon^  have  shown  most  beautifully  by  their 
experiments  how  emotional  (mental)  states  influence  the  bodily 
functions.  Pawlow  has  shown  that  the  physiological  pocesses, 
the  flow  of  saliva,  could  be  brought  about  reflexly  by  stimuli  of 
sight,  sound,  touch,  variation  of  temperature,  odor,  provided  only 
the  stimulus  had  been  applied  in  association  with  the  giving  of 
food.  Having  applied  the  stimulus  originally  thus  associated  the 
flow  of  saliva  took  place  later  although  this  association  was  left 

-  Yerkes  and  Morgulis :  The  Method  of  Pawlow  in  Animal  Psychology, 
Psych.  Bulletin,  August  15,  1909. 

■"'  Cannon,  W.  B. :  Bodily  Changes  in  Pain,  Hunger,  Fear  and  Rage.  D. 
Appleton  Co.,  New  York,  1915. 


THE    NATURE   OF    MENTAL   DISORDER.  1 5 

out.  The  physiological  process  had  become  organically  linked 
with  the  nervous  stimulus,  a  conditioned  reflex  was  established. 
This  is  a  form  of  explanation  which  Watson  in  particular  has 
used  to  account  for  the  over-importance  which  attaches  to  some 
ideas  and  feelings  in  the  neuroses. 

Here  the  much  vexed  question  of  the  relation  of  mind  to  body 
is  touched  upon.  An  appeal  to  facts  would  show  that  the  indi- 
vidual reacts  to  his  milieu  by  the  development  of  mechanisms  that 
may  include  as  parts  the  crass  physical  at  one  end,  the  refined 
psychic  at  the  other.  In  these  experiments  of  Pawlow  and 
Cannon,  for  example,  mechanisms  were  created  which  acted  as  a 
whole.  Like  a  watch,  the  parts  were  so  intimately  related  that 
no  portion  could  be  set  in  motion  without  setting  the  whole  going. 

Even  when  a  portion  of  the  mechanism  is  destroyed  the  rest 
often  still  operates.  The  decerebrate  dog  turns  and  growls  and 
bites  at  the  fingers  that  hold  his  hind  foot  too  roughly.  Here 
there  cannot  be  any  possibility  of  the  conscious  psychic  state  of 
anger,  as  Sherrington*  says,  "  The  action  occurs,  and  plays  the 
pantomime  of  feeling ;  but  no  feeling  comes  to  pass." 

The  action  of  a  complex  mechanism  as  a  whole  is  shown  excep- 
tionally well  in  a  case  reported  by  Prince.^  The  patient  was 
subject  to  hay  fever  in  a  very  severe  form  when  exposed  to  roses. 
On  one  occasion  a  bunch  of  roses  was  unexpectedly  produced 
from  behind  a  screen.  A  severe  attack  followed  with  lachryma- 
tion,  congestion  of  the  mucosa,  dyspnea,  etc.,  although  the  roses, 
unknown  to  the  patient,  were  paper  ones.  Here  a  pure  psychic 
fact  at  one  end  of  the  scale  produces  a  set  of  reactions  which  at 
the  other  gives  rise  to  sensory,  motor,  vaso-motor,  and  secretory 
disturbances  of  a  definitely  somatic  character.  The  important  fact 
is  that  from  the  one  to  the  other  there  is  an  uninterrupted  chain  of 
associations. 

I  have  shown  by  these  illustrations  (and  in  Chapter  I)  that  the 
adjustment  of  the  individual  as  a  whole  to  the  environment  is  a 
mental  function.  Of  course  in  general  such  an  adjustment  con- 
stitutes life  itself,  which  as  defined  by  Spencer  is  "  the  continu- 

*  Sherrington :  The  Integrative  Action  of  the  Nervous  System.  London, 
Archibald  Constable  &  Co.,  1906. 

5  Prince:  The  Unconscious,  Jour,  of  Abnormal  Psych.,  Vol.  Ill,  Nos.  4, 
5  and  6;  Vol.  IV,  No.  i. 


1 6  OUTLINES   OF   PSYCHIATRY. 

ous  adjustment  of  internal  relations  to  external  relations."  With 
the  human  being,  however,  the  conditions  are  more  complex. 
The  adjustment  is  not  limited  in  the  passive  way  implied  thus  far. 
The  individual  assumes  an  active  part  towards  his  environment 
and  endeavors  to  shape  it  in  accord  with  a  pattern  partly  con- 
scious, partly  unconscious.  He  tries  to  utilize  the  world  of  phe- 
nomena to  suit  his  desires.  Thus  we  find  the  individual  not  only 
acted  upon  by  the  environment  and  molded  thereby  but  the  en- 
vironment reacted  upon  by  the  individual  who  endeavors  to  shape 
it  to  his  needs.  It  is  in  these  strivings  that  the  unconscious  tend- 
encies play  a  continuous  and  a  determining  part. 

It  therefore  follows  that  the  most  complete  mental  life  is  that 
which  best  adjusts  the  individual,  both  passively  and  actively  in 
the  sense  just  described,  to  the  conditions  of  his  environment: 
the  best  mind,  that  which  is  capable  of  the  greatest  latitude  of 
adjustment,  that  enables  the  possessor  to  fill  any  position  in  life 
in  which  he  may  be  placed.  And  conversely,  the  poor  mind,  the 
narrow  mind,  permits  only  a  limited  adjustment,  either  limited  in 
the  particular  position  of  life  occupied  by  the  individual  or  limited 
as  to  its  possibilities  of  scope,  or  both.  The  mental  life  is  carried 
on  within  relatively  narrow  limits. 

Whatever  may  be  the  limits  of  adjustability  for  the  individual, 
any  disorder  of  the  mental  processes  must  necessarily  interfere 
with  it.  But  as  standards  of  comparison  are  relative  we  are 
forced  to  compare  the  individual's  present  condition  with  his  con- 
dition in  the  past,  with  his  usual  condition.  Thus  all  degrees  of 
adjustability  are  found  in  different  people  and  the  most  limited 
for  the  individual  concerned  may  be  normal.  The  interference 
with  the  adjustment  of  the  individual  with  his  environment  is 
therefore  a  disorder  in  so  far  as  it  is  a  departure  from  his  pre- 
vious, his  usual  condition. 

From  the  standpoint  of  disordered  mental  functioning,  a  psy- 
chosis is  the  expression  on  the  part  of  the  individual  of  his  type 
of  reaction  to  the  conditions  of  his  environment.  The  mental 
symptoms  of  the  psychoses  can  be  spoken  of  as  a  disease  only  in 
the  sense  that,  and  in  so  far  as,  they  represent  failure  on  the  part 
of  the  individual,  a  lack  of  capacity  for  efficient  adjustment. 

In  thinking  of  mental  disorders  as  results  of  failures  to  effect 
harmonious  adjustment  we  must  think  in  terms  of  attempts  at 


THE   NATURE   OF    MENTAL   DISORDER.  1 7 

repair,  adjustment  and  compensations  as  we  have  learned  to  in 
the  somatic  diseases.  We  are  familiar  with  these  processes  in 
general  pathology.  We  know  the  processes  of  repair  in  tissues 
that  have  been  injured,  we  are  familiar  with  the  way  the  organs 
adjust  themselves  to  deforming  forces,  such  as  tumors;  we  know 
how  defects  such  as  a  mitral  insufficiency  is  compensated  for  by 
the  hypertrophy  of  the  heart  muscle.  So  in  the  mental  sphere 
we  find  persons  struggling  with  conditions,  trying  to  solve  prob- 
lems, sometimes  succeeding,  sometimes  failing,  sometimes  com- 
promising. 

With  the  successes  we  have  nothing  to  do;  with  the  failures 
we  must  deal.  In  its  efforts  at  adjustment  the  mental  functions 
develop  many  ways  of  reacting.  They  defend  the  individual  from 
disagreeable  experiences  often  by  forgetting  them,  i.  e.,  by  thrust- 
ing them  into  the  unconscious.  For  certain  experiences  that 
cannot  be  adequately  adjusted  to  certain  compensatory  reactions 
are  evolved.  The  young  woman  disappointed  in  love  is  com- 
pensated by  a  life  devoted  to  the  service  of  others,  or  perhaps  if 
the  conflict  is  too  severe  she  may  develop  a  wish- fulfilling  delirium 
and  thus  by  a  vicarious  psychosis  cause  all  her  desires  to  be  real- 
ized, or  if  the  conflict  reaches  deeper  she  may  deteriorate  and 
develop  delusions  which  express  compensations  more  or  less 
adequate  in  proportion  to  the  degree  of  so-called  dementia  or  of 
mental  disintegration. 

The  important  thing  to  remember  is  that  no  mental  fact  is 
fortuitous,  it  has  its  adequate  mental  explanation.  Ideas  cannot 
exist  alone;  what  does  exist  is  a  mental  state  constellated  by 
events  in  the  environment  and  related  to  those  events. 

Every  mental  state  is  a  synthesis  and  like  a  chemical  compound 
may  bear  little  relation  in  its  qualities  to  the  qualities  of  its  con- 
stituent elements.  Every  mental  state,  too,  reaches  back  through 
an  immeasurable  line  of  other  mental  states  to  the  very  dawn  of 
consciousness.  Bergson^  puts  it  thus — "  Doubtess  we  think  with 
only  a  small  part  of  our  past,  but  it  is  with  our  entire  past,  in- 
cluding the  original  bent  of  our  soul,  that  we  desire,  will  and  act." 
There  is  nothing  fortuitous  in  mental  life.  Determinism  holds 
as  definitely  in  the  psychic  as  in  the  physical  world  and  no  mental 
fact  can  exist  that  has  not  its  efficient  cause  in  antecedent  mental 

^Bergson:  Creative  Evolution.    New  York,  Henry  Holt  &  Co.,  191 1. 


1 8  OUTLINES    OF   PSYCHIATRY. 

states.  The  sum  total  of  the  mental  material  constitutes  the 
personality.  All  states  of  mind  have  efficient  causes  and  are 
definitely  associated  with  those  causes  in  quite  as  inevitable  a  way 
as  in  the  physical  world. 

It  must  be  remembered  in  considering  the  constitution  of  con- 
sciousness that  full  consciousness  is  only  concerned  with  adjust- 
ments that  are  relatively  new  and  unusual;  conditions  which,  not 
having  been  met  before,  permit  of  reactions  in  any  one  of  several 
directions.  When  mental  acts  have  occurred  repeatedly  in  re- 
sponse to  the  same  sort  of  circumstances  they  become  progres- 
sively less  and  less  conscious  and  finally  pass  to  the  level  of  the 
automatic  as  the  result  of  the  development  of  a  well  defined,  rela- 
tively stable  mechanism.  The  familiar  example  of  the  piano 
player  will  illustrate  this  progressive  change.  At  first  while 
learning,  each  movement  is  painfully  conscious,  the  fingers  have 
to  be  watched,  each  note  separately  observed,  and  the  required 
movements  are  slowly  and  awkwardly  executed.  When  pro- 
ficiency has  been  acquired  the  same  results  are  accomplished  far 
better,  with  much  less  effort,  and  with  so  little  attenion  that  an 
occasional  glance  over  the  shoulder  and  the  entering  into  the  con- 
versation of  those  about  do  not  seem  to  interfere  with  the  play- 
ing. The  processes  involved  have  passed  beyond  the  level  of 
clear  consciousness  to  a  stage  of  semi-automatism. 

If  we  will  consider  the  infinitude  of  adjustments  that  the  indi- 
vidual has  to  make  to  his  environment  it  will  be  seen  that  this  is 
a  conservative  process.  As  soon  as  a  given  adjustment  is  well 
formed  it  is  pushed  aside  and  the  field  of  consciousness  left  free 
for  new  problems.  This  conclusion  is  well  expressed  in  the  fol- 
lowing quotation  -J  "  There  exists  a  conviction,  fairly  widespread, 
that  the  function  of  consciousness  is  that  of  adjustment,  that  is, 
that  consciousness  appears  at  moments  of  conflict;  and  there  is 
reluctance  in  admitting  that  adjustment  may  take  place  just  as 
well  without  it,  that  novel  conclusions,  as  some  observers  report, 
may  issue  apart  from  it." 

In  other  words — clear,  full  consciousness  accompanies  only 
those  mental  states  accompanying  adjustment  to  new  and  unusual 
conditions ;  conditions  permitting  of  various  reactions  and  involv- 
ing therefore  selective  judgment,  critique,  choice — in  short,  rea- 

^  I  am  unable  to  locate  the  source  of  this  quotation. 


THE    NATURE  OF   MENTAL   DISORDER.  1 9 

son;  and  in  proportion  to  the  frequency  of  the  repetition  of  the 
same  adjustment  the  mental  state  accompanying  such  repetition 
tends  to  pass  out  of  the  field  of  clear  consciousness.  Stated  in 
this  way  the  method  of  reaction  will  be  seen  to  have  a  biological 
significance  and  not  merely  an  individual  or  even  human  impor- 
tance. Ideas  neither  arise  spontaneously  nor  do  they  exist  with- 
out having  established  relations  with  other  ideas.  The  relation- 
ships thus  established  are  brought  about  and  cemented  by  the 
emotional  content  of  the  event  which  brings  them  together  and 
they  bear  thus  a  relation  of  interdependence  as  among  them- 
selves— they  are  constellated.  These  constellations  exist  as  the 
mental  counterparts  of  events  and  correspond  to  experiences 
which  have  emotional  content  and  operate  to  control  conduct 
though  for  the  most  part  they  are  separated  from  full  clear 
consciousness. 

The  standpoint  of  this  functional  psychology  is  distinctly  dif- 
ferent from  that  of  a  static  psychology.  Until  its  development 
the  attitude  of  the  psychiatrist  was  that  of  the  systematic  biol- 
ogist classifying  the  several  cases  into  families,  genera,  species, 
but  classifying  upon  the  basis  of  the  obvious  symptoms  only. 
The  keynote  of  the  new  standpoint  is  its  distinctly  individual- 
istic trend. 

The  fundamental  conception  of  this  individualistic  viewpoint 
is  that  every  psychic  fact  must  have  been  preceded  by  an  efficient 
psychic  cause.  Ideas,  or,  better,  mental  states,  do  not  arise 
de  novo.  They  must  be  the  outcome  always  of  other  mental 
states  from  which  they  necessarily  issue.  This  is  so  throughout 
the  field  of  psychopathology  even  in  the  realm  of  the  so-called 
organic,  the  psychoses  associated  with  well  defined  brain  changes. 
That  an  alcoholic  should  have  delirium  may  well  be  dependent 
upon  a  toxemia,  but  whether  in  his  delirium  he  sees  snakes  or 
monkeys,  visions  of  his  office,  or  of  hell,  must  depend  upon  purely 
psychic  causes,  upon  the  preexisting  psychic  material  which  has 
become  involved  in  the  disorder.  Whether  a  paretic  is  exalted  or 
depressed,  whether  the  exaltation  is  largely  erotic  or  expresses 
itself  by  delusions  of  great  wealth,  must  find  its  explanation  in 
the  mental  make-up  of  the  person  afflicted  and  the  character  of 
his  psychic  trends.  The  cards  may  be  indefinitely  shuffled  or 
arranged  in  any  way  but  there  are  only  fifty-two  or  them,  and 


20  ■  OUTLINES    OF   PSYCHIATRY. 

the  result,  whatever  it  may  be,  is  conditioned  and  delimited  by 
that  fact.  This  illustration  should  not,  of  course,  be  taken  too 
literally  because  new  psychic  facts,  new  material,  new  cards,  are 
added  during  the  course  of  the  psychosis.  The  fact  intended  to 
be  emphasized  is  that  the  disease  process  can  only  deal  with  the 
material  it  finds  at  hand  or  has  furnished  it,  that  it  itself  does 
not  create. 

With  this  fundamental  conception  the  psychiatrist  is  in  a  posi- 
tion to  remind  us  of  the  chemist  or  the  astronomer.  If  there  is 
a  hiatus  in  the  logical  connections  of  the  different  steps  in  a  psy- 
chosis, like  the  chemist  he  can  with  confidence  look  for  an  element 
to  fill  the  space.  If  there  is  a  disturbance  somewhere  along  the 
line,  like  the  astronomer,  he  may  expect  to  find  a  hitherto  un- 
known source  of  energy  to  account  for  it. 

This  deterministic  attitude  of  present  day  psychology',  this 
hypothesis  that  every  bit  of  conduct  is  an  end  product  conditioned 
by  what  has  gone  before  and  out  of  which  it  issues  lead  us  to  an 
historical  examination  of  the  symptoms  of  the  psychoses  for  their 
interpretation.  A  complete  history  of  the  symptoms  is  therefore 
an  explanation  of  them. 

Inasmuch  as  the  symptoms  must  be  explained  by  an  uncovering 
of  their  past  it  follows  that  a  psychosis  is  a  form  of  reaction  which 
can  only  be  interpreted  if  we  know  the  history  of  the  development 
of  the  individual.  It  goes  without  saying  that  the  general  scheme 
of  development  is  the  same  for  all,  it  only  differs  in  respect  to  the 
relative  emphasis  placed  upon  certain  elements,  therefore  we 
should  expect  to  find  an  explanation  of  the  psychosis  to  lie  in  the 
nature  and  extent  of  the  deviations  from  the  normal  course  of 
development  and  the  content  of  the  psychosis  to  consist  of  the 
material  the  individual  had  acquired  along  the  way. 

The  psychosis  is  the  resultant,  the  issue  for  the  time  being,  of 
a  conflict.  The  conflict  is  between  unsatisfied,  instinctive  desires 
which  have  been  repressed  into  the  region  of  the  unconscious, 
and  the  conscious,  voluntarily  directed  tendencies  of  the  individual. 
There  are  several  hypotheses  to  account  for  the  psychosis  on  the 
basis  of  such  a  conflict.     I  will  briefly  indicate  them. 

Freud  believes  that  the  tendencies  that  are  repressed  in  the  un- 
conscious are  directed  by  the  pleasure-pain  motive  to  conduct  and 
the  pleasure  sought  is  of  a  libidinous — sexual — nature.     In  the 


THE   NATURE  OF   MENTAL  DISORDER.  21 

course  of  development  certain  forms  of  pleasure  seeking  have  re- 
ceived undue  emphasis;  the  child  has  for  some  reason  continued 
to  derive  pleasure  from  some  activity,  nakedness  (exhibitionism), 
sexual  curiosity  (peeping),  inflicting  pain  on  self  or  others  (sado- 
masochism), sexual  yearnings  for  the  parent  of  the  opposite  sex 
(incest),  pleasure  in  its  own  sensations  (auto-erotism),  love  of 
children  most  like  itself,  of  the  same  sex  (homosexuality),  which 
should,  as  a  source  of  pleasure,  have  been  relegated  to  its  historic 
past,  and  that  therefore  the  necessity  for  deriving  pleasure  in  this 
way  is  greater  than  normal  and  tends  constantly  to  find  expression. 
Such  ways  of  pleasure  seeking  are  incompatible  with  the  conscious 
ideals  and  so  can  only  come  to  expression  in  some  disguise.  The 
way  in  which  these  tendencies  are  satisfied  and  the  disguises  they 
assume  produce  the  symptoms  of  the  psychoses.  For  example  a 
homosexual  man  who  could  not  bring  himself  to  consciously  think 
of  concrete  homosexual  experiences  may  engage  in  welfare  work 
among  men.  The  sexual  interest  is  drafted  ofif  at  a  higher, 
socially  acceptable  and  useful  level,  it  is  sublimated.  When  such 
a  man,  however,  is  unable  to  fully  sublimate  his  homosexual  libido 
he  may  take  to  alcohol  because  it  brings  him  into  the  company 
of  men  and  permits  a  degree  of  intimacy  under  the  guise  of  intoxi- 
cation that  would  not  otherwise  be  possible.  If  his  sublimation 
fails  still  more  completely  he  may  develop  a  psychosis  with 
hallucinations  of  hearing  in  which  the  voices  accuse  him  of  homo- 
sexual practices. 

Jung,  on  the  other  hand,  emphasizes  the  importance  of  the 
present  difficulties,  the  impossibility  of  the  libido  finding  an  ade- 
quate outlet  because  of  some  obstacles.  A  man  may  be  in  love 
with  some  one  who  is  impossible  because  of  social  or  financial 
barriers  or  because  the  love  is  not  returned.  The  libido  is  thus 
blocked  in  its  efforts  to  attach  itself  to  a  suitable  object  and  the 
conflict  brings  into  the  foreground  ways  of  using  the  libido  which 
had  been  efficient  in  the  past.  Men,  for  example,  taken  from 
their  families  and  put  aboard  ship  for  a  long  voyage  revert  to 
masturbation  or  to  homosexual  practices. 

Adler,  however,  deals  more,  in  his  hypotheses,  with  the 
ego-  (self-preservative)  instinct  rather  than  with  the  sexual,  and 
sees  in  the  psychoses  a  conflict  due  to  the  desire  to  dominate  which 
is  frustrated  by  a  feeling  of  inferiority  based  upon  some  inherent 


22  OUTLINES   OF  PSYCHIATRY. 

organic  defect.  A  man  who  has  a  definite  defect  such  as  a  defect 
of  speech  feels  that  that  is  his  weak  point  and  he  therefore  directs 
a  surplus  of  energy  to  endeavoring  to  overcome  it.  He  may  thus 
become  a  public  speaker  (Demosthenes)  or  if  he  is  unable  suffi- 
ciently to  overcome  his  feeling  of  inferiority  he  may  break  down 
with  a  psychosis  or  develop  an  over-sensitiveness  with  reference 
to  his  defect  with  ideas  of  reference,  thinking  that  people  notice  it, 
remark  about  it,  etc. 

Kempf^  more  recently  has  correlated  all  these  factors  relating 
to  the  unconscious  tendencies  to  conduct  based  upon  unsatisfied 
instinctive  desires  and  laid  particular  emphasis  upon  the  necessity 
for  studying  the  motor  sets  of  the  individual  (paths  of  discharge — 
emotional,  ideational,  muscular,  neural,  glandular,  etc.)  for  the 
dififerent  instinctive  tendencies.  His  approach  to  the  problems 
tends  in  a  much  more  definite  way  than  any  other  to  eliminate  the 
difficulties  which  arise  from  the  constantly  emphasized  distinction 
between  mind  and  body.  Emotions,  muscular  tensions,  and  all 
sorts  of  secretory  anomalies  are  then  understood  as  belonging  to 
actions  which  are,  so  to  speak,  held  within  the  body,  not  permitted 
to  come  to  pass.  The  symptoms  of  the  neuroses  and  psychoses  are 
then  the  symbolic  language  of  the  unsatisfied  instinctive  desires 
translated  into  the  motor  sets  which  are  appropriate  for  fulfilling 
them,  but  which  owing  to  their  conflict  with  the  conscious  per- 
sonality ideals  are  not  permitted  to  gain  their  ends  by  being 
translated  into  conduct. 

In  dealing  with  the  conflict  the  individual  may  take  one  of  two 
methods — follow  one  of  two  paths.  He  may  turn  back  upon  and 
within  himself,  that  is,  retrace  the  path  of  development  along 
which  he  has  come  until  he  comes  to  a  point  at  which  he  succeeds 
in  getting  a  sufficiently  satisfactory  expression,  for  example,  a 
person  who  has  inadvertantly  caused  the  death  of  some  one  (a 
nurse  who  mistakenly  gave  a  poisonous  dose  of  medicine)  may 
revert  to  a  period  in  her  development  antedating  the  unbearable 
emotional  experience  and  become  again,  as  it  were,  a  young  girl 
with,  therefore,  all  knowledge  of  the  experience  effaced  from  her 
memory.  The  whole  period  of  her  life  as  a  nurse  may  be  wiped 
out  and  so  the  event  is  as  if  it  never  had  been.  This  is  the  method 
of  reaction  by  introversion. 

8  Kempf,  E.  J. :  The  Autonomic  Functions  and  the  Personality.     Nerv. 
and  Ment.  Disease  Monograph  Series,  No.  27. 


THE    NATURE   OF   MENTAL   DISORDER.  2^ 

On  the  contrary  some  individuals,  differently  constituted  do 
just  the  opposite.  They  run  away  from  their  conflict  not  by  turn- 
ing back  within  themselves  but  by  running  into  reality.  Their 
"flight  into  reality"  takes  the  form  of  an  active  interest  in  every- 
thing and  every  person  that  touches  their  lives  in  any  way. 
Everything  attracts  their  libido.  Unfortunately  they  are  usually 
too  distractable,  not  being  able  to  confine  their  interests  in  any  one 
direction  long  enough  to  be  efficient.  This  is  the  method  of  reac- 
tion by  extroversion.  Dementia  precox  is  the  type  of  introversion 
psychosis,  manic-depressive  psychosis,  particularly  the  manic 
phase,  is  the  type  of  extroversion  psychosis. 

The  symptoms  of  the  neuroses  and  psychoses  can  thus  be  seen 
to  be  further  qualified  by  the  way  in  which  the  individual  reacts  to 
his  conflict — by  introversion  or  by  extroversion.  Finally,  as  I 
have  already  indicated,  there  is  a  large  individual  content  to  the 
psychoses  (special  delusional  ideas,  the  specific  things  the  hallu- 
cinatory voices  say,  etc.)  which  has  its  explanation  in  the  experi- 
ences of  the  individual  along  the  way. 


CHAPTER   IV. 

Classification  of  Mental  Disorders. 

Classifications  are  of  service  in  as  much  as  they  offer  a  con- 
densed resume  of  existing  conceptions  concerning  the  nature  and 
relationships  of  the  things  classified.  They  furthermore  serve  to 
render  new  conceptions  more  concrete,  which  otherwise  would 
tend  to  remain  in  their  older  settings  and  thus  be  less  useful. 
The  more  complex  the  set  of  relations  to  be  brought  together  the 
greater  the  number  of  attempts  at  generalization  and  the  greater 
the  disparity  in  points  of  view. 

Thus  when  the  question  of  the  classification  of  the  different 
psychoses  is  approached  a  condition  of  affairs  is  found  which 
leaves  much  to  be  desired.  The  problem  of  classification  has  been 
approached  from  every  side:  the  psychological,  the  pathological, 
the  etiological,  and  the  clinical,  and  while  some  authors  adhere 
to  one  point  of  view  the  majority  do  not,  but  offer  a  classification 
based  on  all  four  considerations.  This  latter  position  is  prac- 
tically necessary  as  there  are  types  of  mental  disorder  which  lend 
themselves  only  to  classification  from  one  of  these  standpoints 
and  find  no  classification  on  any  other  basis. 

As  a  matter  of  fact  our  knowledge  of  the  psychoses  is  alto- 
gether too  limited  at  present  to  justify  the  expectation  that  the 
problem  of  classification  can  be  solved.  Any  attempt  at  grouping 
mental  disorders  under  separate  heads  must  now,  as  always,  be 
but  tentative  and  incomplete.  Classifications  grow  with  chang- 
ing concepts,  they  represent  roughly  and  in  concrete  way  stages 
of  development  and  should  only  be  considered  from  that  stand- 
point. They  cannot  be  literally  compared  as  the  very  words  ot 
which  they  are  composed  also  grow  and  change  in  meaning  with 
the  passage  of  time.  I  will  not  attempt  to  offer  any  exhaustive 
scheme  of  classification  but  in  the  various  chapters  of  this  work 
will  discuss  the  forms  of  mental  disorder  which  are  generally 
acknowledged  to  exist  and  while  endeavoring  to  give  a  clear 
picture  of  types  will  take  the  broad  view  which  realizes  that  the 

24 


CLASSIFICATION  OF   MENTAL  DISORDERS.  2$ 

different  forms  of  mental  derangement  are  not  capable  of  clean- 
cut  demarkations  but  that  on  the  contrary  many  of  the  present 
groups  will  in  the  course  of  time  be  broken  up  into  smaller  groups 
as  we  come  to  more  accurately  differentiate  cases  and  appreciate 
more  fully  the  true  value  of  signs  and  symptoms.  In  fact,  disease 
types  are  not  absolutely  definite  things  and  each  and  every  case 
need  not  of  necessity  be  classified  under  one  and  only  one  caption 
for  all  time.  A  diagnosis  that  is  in  order  to-day  may  be  quite 
useless  and  passe  six  months  hence,  while  aside  from  the  fact 
that  in  the  course  of  the  chronic  psychoses  acute  symptoms  may 
develop  which  have  no  relation  to  the  fundamental  disease  type 
we  must  appreciate  the  fact  that  there  are  many  cases  that  so 
truly  partake  of  the  symptoms  of  two  psychoses  as  to  make  their 
relegation  to  either  group  equally  impossible.  Then  again  within 
the  larger  groups  all  grades  of  transition  cases  may  be  found, 
while  a  certain  few  cases  defy  all  attempts  at  classification 
whatever. 

The  psychoses  include  a  great  multitude  of  different  condi- 
tions— of  different  sorts  of  reaction — due  to  a  host  of  different 
kinds  of  causes  and  the  explanation  of  the  difficulty,  in  fact  the 
impossibility  of  classifying  mental  disorders  on  any  one  basis — 
the  etiological,  the  pathological,  the  psychological — is  at  once 
apparent.  It  would  be  just  as  sensible  to  try  and  force  under 
one  head  all  the  diseases  that  might  involve  the  kidney,  including 
sarcoma  and  tuberculosis  with  the  nephritides  proper. 

It  is  true  that  the  symptoms  of  mental  disorder  tend  to  arrange 
themselves  into  groups,  but  the  constancy  of  these  groups  is  a 
very  variable  factor,  and  like  the  epileptologist  who  no  longer 
speaks  of  epilepsy  as  a  concrete  entity  but  speaks  rather  of  the 
epilepsies,  so  we  are  getting  away  from  the  idea  of  distinct,  defi- 
nite psychoses  and  are  using  such  terms  as  the  dementia  paralytica 
group,  the  manic-depressive  group,  the  hysteria  group,  etc. 

These  groups,  the  so-called  clinical  types,  are  not  clean-cut 
entities  but  are  only  groups  of  symptoms  which  either  seem  to 
occur  more  frequently  in  combination  or  else  have  been  more 
definitely  and  clearly  seen  because  of  the  nature  of  that  combi- 
nation. In  fact  classical  types  as  such  may  be  said  to  be  in  the 
minority.  The  great  mass  of  cases  seen  are  combinations  more  or 
less  intermediate  in  character.    The  conception  of  types  in  order 


26  OUTLINES   OF  PSYCHIATRY. 

to  be  accurate  must  be  from  a  broad  biological  viewpoint.  Types 
are  like  species.  They  have  innumerable  transition  and  inter- 
mediate forms.  It  is  as  if  overlooking  a  vast  though  young  forest. 
Here  and  there  are  certain  trees  which  because  of  their  size  or 
prominent  location  stand  out  distinct  from  the  others.  These 
would  at  once  be  picked  out  by  the  observer  as  types,  yet  the 
forest  as  a  whole  is  not  composed  of  these  but  of  the  immense 
number  of  smaller  trees  among  which  these  few  stand  out  defi- 
nitely, and  a  more  detailed  study  of  the  majority  of  the  trees  of 
approximately  the  same  size  would  reveal  minor  differences  of 
structure;  for  example,  in  the  form  of  leaf,  thickness  of  bark, 
inclination  of  branches,  color  of  flowers,  etc.,  many  of  which 
might  only  serve  to  distinguish  the  individuals,  while  others 
would  be  of  sufficient  importance  to  constitute  varieties,  or  even 
species. 

Insanity^  is  not  a  disease ;  it  is  rather  a  symptom  grouping  for  a 
large  number  of  different  mental  diseases  which  tend  to  arrange 
themselves  with  greater  or  less  distinctness  into  circumscribed 
groups  of  reaction  trends.  The  study  of  psychiatry  is  therefore 
primarily  a  study  of  disordered  function  and  must  be  conducted 
not  only  in  the  autopsy  room  but  in  the  psychological  laboratory. 
And  this  study  will  only  reach  its  full  fruition  when  the  results  of 
the  detailed  analyses  of  aberrant  reaction  trends  are  correlated 
with  the  results  of  a  study  of  the  mental  "  make-up  "  of  the  indi- 
vidual before  he  becomes  mentally  sick. 

This  is  well  illustrated  clinically  when  we  consider  any  one  of 
the  etiological  factors  of  a  mental  disorder.  Take  for  example 
alcohol.  There  are  a  number  of  psychoses  that  seem  to  occur 
almost  solely  under  the  influence  of  alcohol.  Of  the  various 
so-called  alcoholic  psychoses  one  patient  will  develop  delirium 
tremens,  another  acute  hallucinosis,  a  third  KorsakoAv's  psychosis. 
What  conditions  the  special  form  of  psychosis  in  each  case  is  not 

1  Insanity  should  not  be  used  as  a  medical  term  at  all.  It  is  solely  a 
legal  and  sociological  concept  and  so  used  to  designate  those  members  of 
the  community  who  are  so  far  from  able  to  adjust  to  the  ordinary  social 
requirements  that  the  community  segregates  them  (forcibly  perhaps)  and 
takes  away  their  rights  as  citizens.  Insanity  is  a  form  of  social  inade- 
quacy which  medically  may  be  the  result  of  many  varieties  of  mental  dis- 
ease.   Insane,  therefore,  means  nothing  more  than  certifiable. 


CLASSIFICATION    OF    MENTAL  DISORDERS.  27 

definitely  known.  On  the  other  hand  certain  patients  as  a  result 
of  alcohol  develop  quite  dififerent  psychoses,  the  alcohol  perhaps 
conditioning  the  outbreak  of  an  attack  of  manic-depressive  psy- 
chosis, or  it  may  condition  the  breakdown  of  dementia  precox, 
or  accelerate  the  development  of  paresis. 

The  study  of  character  trends  has,  fortunately,  begun  to  be 
appreciated  and  is  already  accumulating  a  considerable  literature 
and  leading  to  very  suggestive  results.  We  have  for  some  time 
known  very  well,  in  a  general  way,  the  unbalanced  character,  the 
epileptic  character,  the  hysterical  character,  and  the  unresistive 
character  recognized  so  often  in  general  medicine  because  of  the 
abnormal  reaction  to  febrile  disturbances,  easily  developing  de- 
lirium as  a  result  of  only  a  moderate  fever,  and  while  recent 
studies  have  outlined  the  differences  in  character  as  manifested 
by  sex,  a  beginning  is  being  made  in  the  recognition  of  those  types 
that  may  later  develop  a  psychosis.  There  are  definite  types  of 
character  which  tend  under  appropriate  conditions  to  develop  the 
manic-depressive  type  of  reaction  while  others  tend  to  the  devel- 
opment of  deterioration  types. 

The  individual  is  a  biological  unit  and  must  be  so  considered 
in  relation  to  other  individuals,  to  society.  If  this  is  forgotten 
the  perspective  is  lost.  The  end  and  aim  of  psychiatry  is  no 
longer  considered  to  be  either  to  find  a  diseased  nerve  cell  or  to 
make  a  hard  and  fast  diagnosis  of  a  given  condition  at  a  given 
time.  If  we  are  to  understand  the  psychosis  we  must  understand 
the  individual,  we  must  study  not  only  his  origin  and  development 
but  his  adjustment  to  conditions.  A  psychosis  cannot  be  under- 
stood by  subjecting  it  to  cross-section  for  the  purpose  of  defining 
its  content  at  a  particular  point,  or  by  subjecting  it  to  longitudinal 
section  for  the  purpose  of  tracing  the  beginning  and  the  end  of 
symptoms.  Such  subjection  to  the  narrow  field  of  an  optical 
section  will  not  do — it  must  be  studied  as  a  life  history.  Our 
patients  must  be  considered  as  individuals  who  under  certain  con- 
ditions have  reacted  in  certain  ways.  The  type  of  reaction  can 
only  reach  its  explanation  in  the  type  of  person  displaying  it. 

The  symptom  picture  of  any  psychosis  must  be  dependent  then 
upon  two  factors — the  present  make-up  and  the  etiological  mo- 
ment, using  this  term  in  its  broadest  sense  as  meaning  the  deter- 
mining cause  of  the  symptoms.    In  this  sense  it  would  include  an 


28  OUTLINES   OF  PSYCHIATRY. 

organic,  pathological  condition.  Only  with  such  a  viewpoint  can 
these  borderland  conditions  be  understood. 

The  important  thing  is  an  understanding  of  the  patient,  not  a 
labeling  of  the  psychosis.  To  this  end  a  comprehension  of  the 
character  make-up,  the  nature  of  the  etiological  factors,  and  the 
mechanism  of  the  reaction  must  be  known.  So  much  at  least 
must  we  know  and  then  whether  we  give  one  name  or  another 
to  our  resulting  conception,  or  no  name  at  all,  matters  little. 

In  fact  the  very  giving  of  a  name  has  its  distinct  dangers,  for 
it  means  only  too  often  a  cessation  of  interest.  For  example,  a 
patient  is  labeled  dementia  precox  and  forthwith  consigned  to 
hopelessness  and  oblivion  because  to  the  person  giving  the  name  the 
name  has  that  significance.  I  am  convinced  of  the  great  danger  of 
giving  names  and  emphasize  in  my  teaching  the  mechanisms  in- 
volved, try  to  show  what  the  patient  is  trying  to  do  by  means  of 
his  psychosis,  interpret  the  meaning  of  his  conduct,  his  symptoms, 
as  indicated  in  the  last  chapter.  Names  nevertheless  become  more 
or  less  necessary  as  means  of  conveying  thought.  With  the 
qualifying  limitations  indicated  I  will  discuss  the  psychoses  under 
the  following  captions. 

1.  Paranoia  and  Paranoid  States. 

2.  Manic-Depressive  Psychoses. 

3.  Paresis. 

4.  Dementia  Precox. 

5.  Pre-Senile,  Senile  and  Arteriosclerotic  Psychoses, 

6.  Infection-Exhaustion  Psychoses. 

7.  Toxic  Psychoses. 

8.  Psychoses    Associated    with    Organic    Diseases    and 

Injury  of  the  Brain. 

9.  The  Symptomatic  Psychoses. 

10.  Borderland  and  Episodic  States. 

11.  Idiocy  AND  Imbecility. 


CHAPTER  V. 

Causes  of  Mental  Disorders. 

While  it  is  fully  realized  that  mental  disorders  are  so  various 
that  a  general  chapter  on  their  causes  is  quite  as  illogical  as  would 
be  a  chapter  on  the  causes  of  fever  in  a  work  on  general  medicine, 
still  there  are  a  number  of  practical  issues  that  may  be  discussed 
in  such  a  chapter  and  which  I  think  justify  it. 

As  in  other  departments  of  medicine,  so  here,  we  find  two 
classes  of  causes  operative — predisposing  and  exciting.  The  pre- 
disposing causes  are  made  up  of  those  conditions  existing  within 
the  individual  and  which  render  him  hable  to  the  development 
of  mental  disorder  under  favorable  circumstances.  The  exciting 
causes  are  those  circumstances  or  conditions  which  produce  the 
actual  attack  of  mental  disturbance  operating  usually  upon  pre- 
disposed soil.  The  predisposing  causes  may  be  likened  to  a  train 
of  gunpowder,  the  exciting  causes  to  the  match  that  fires  it. 

The  following  table  sets  forth  in  a  general  way  the  factors  of 
etiological  significance  in  the  development  of  mental  disorders. 

The  predisposing  causes  are  from  their  nature  in  the  main  con- 
stitutional, although  a  predisposition  to  mental  disease  may  be 
acquired,  i.  e.,  by  systematic  poisoning  (alcohol),  the  prolonged 
debilitation  of  disease  (tuberculosis),  etc.  The  exciting  causes 
can  all  be  classified  under  the  general  caption  of  stress,  mental 
or  physical,  exogenous  or  endogenous  and  comprise  the  various 
factors  which  are  immediately  causative  of  the  outbreak  of  the 
attack.     Our  classification  of  causes  would  then  be  the  following : 

Predisposing  Causes. 

Individual:  Inherited  Predisposition. — ^An  inherited  predispo- 
sition to  mental  disorder  is  found  in  from  30  to  90  per  cent,  of 
cases  according  to  different  authorities,  while  the  average  for  all 
conditions  has  been  estimated  at  from  60  to  70  per  cent.  But  any 
one  who  is  at  all  familiar  with  the  collecting  of  statistics  must 

29 


30 


OUTLINES   OF  PSYCHIATRY. 


know  how  impossible  it  is  for  them  to  fully  represent  the  facts 
in  such  a  matter. 


'  Predisposing. 


Causes 

of 

Mental 

Disorder. 


Individual, 


General. 


{Inherited  Predisposition 
(heredity). 
Acquired  Predisposition. 

Age. 

Physiological  Epochs. 
Sex. 

Civil  Condition. 
Climate. 
.  Civilization. 


Exciting 
(stress). 


Physical. 


Exogenous. 
Endogenous. 


_  Mental. 


Toxic. 

Traumatic. 
Infectious. 

Exhaustion. 
Bodily  Disease, 


Acting  over  a  short  period  of 
time — such  as  Fright. 

Acting  over  a  long  period  of 
time — such  as  Worry. 


If  we  will  take  up  any  annual  report  of  an  institution  for 
the  insane^  and  turn  to  the  table  giving  the  causes  of  insanity  in 
the  several  patients  under  treatment,  we  will  find  assigned  such 
causes  as  these :  "  business  anxiety,"  "  death  of  mother,"  "loss  of 
property,"  "  disappointment  in  love,"  "  domestic  troubles,"  "  ex- 
cessive study,"  "political  excitement."  How  many  of  us  but 
have  suffered  at  some  time  or  other  from  some  or  perhaps  all  of 
these  so-called  causes  of  insanity.  Certainly  we  have  all  had 
business  worries ;  certainly  we  have  all  lost  property  at  some  time, 
otherwise  our  good  fortune  is  phenomenal ;  certainly  we  have  all 
been  subject  to  political  excitement  many  times,  and  all  of  us 
prestunably  have  lost  a  dear  friend  or  relative,  perhaps  a  father 
or  mother.     Dr.  Carlos  F.  McDonald  says  very  forcibly  on  this 

1  Using  the  term  with  its  social  significance,  i,  e.,  certifiable.  While 
there  is  no  such  disease  as  insanity  and  the  term  insane  is  not  a  medical 
term  yet  the  designation  of  institutions  as  "  hospitals  for  the  insane "  is 
quite  correct,  for  here  the  word  insane  refers  to  a  social  group  which 
has  been  labelled  such  by  the  legal  powers  provided  (certification). 


CAUSES  OF   MENTAL  DISORDERS.  3 1 

subject,  "...  that  substantially  every  individual  at  some  time 
or  other  during  his  life  is  exposed,  in  many  cases  repeatedly,  to 
many  of  the  so-called  exciting  causes  of  insanity,  both  mental 
and  physical,  and  yet,  despite  this  fact,  we  find  that  sanity  is  the 
rule — insanity  the  exception." 

In  ascribing  these  causes  what  has  been  done  is  simply  this: 
The  particular  set  of  conditions  which  happened  to  maintain  at 
the  time  the  patient  was  attacked  with  a  psychosis  have  been  tabu- 
lated as  the  causes  of  that  attack.  While  they  may  have  had  to 
do  with  the  outbreak  of  the  attack  and  thus  operated  as  exciting 
causes,  the  much  more  important  condition  was  the  unstable 
make-up  of  the  individual  that  made  it  possible  for  such  events 
to  operate  as  causes  at  all.  A  great  deal  of  what  heretofore  has 
been  regarded  as  constitutional,  that  is,  hereditary  is  now  regarded 
by  the  psychoanalysts  as  quite  possibly  individual  and  due  to 
causes  which  at  least  are  preventable.  The  presence  of  uncon- 
scious complexes^  cause  reactions  which  seem'  to  be  constitutional 
only  because  their  real  causes  are  buried  from  sight. 

In  other  words,  the  average  mind,  under  the  influence  of  stress, 
does  not  become  deranged  unless  from  the  operation  of  trauma- 
tism, toxaemia,  or  extreme  degrees  of  exhaustion  and  not  even 
then  with  anything  like  the  facility  of  the  mind  predisposed  to 
disease  by  bad  heredity  or  unconscious  complexes. 

In  dealing  with  the  subject  of  heredity,  however,  it  must  not 
be  forgotten  that  our  ideas  are  of  necessity  largely  founded  upon 
hypotheses,  as  biological  sciences  has  not  yet  unfolded  a  sufficient 
number  of  facts  to  make  it  possible  for  us  to  tell  just  how  much, 
in  any  individual  case,  must  be  attributed  to  the  inherent  quali- 
ties of  the  "germ  plasm "  and  just  how  much  to  the  influences  of 
environment. 

The  view  which  is  pretty  generally  admitted  among  biologists 
at  present  is  that  there  is  Httle  warrant  for  the  belief  in  the 
Lamarckian  hypothesis  of  the  inheritance  of  acquired  characters. 

2  The  term  complex  is  applied  to  a  constellation  of  painful  ideas  which 
have  been  repressed  in  the  unconscious.  A  person  who  is  in  serious  dan- 
ger from  alcohol  may  become  so  rabid  on  the  subject  that  he  cannot  con- 
sider any  angle  of  the  question  calmly.  His  conduct  is  conditioned  by 
his  complex,  though  he  may  have  no  conscious  idea  that  such  is  the  case, 
but  rather  think  that  he  is  advocating  a  temperance  platform  in  an  alto- 
gether normal  way  without  ulterior  motive  (see  chap.  VII). 


32  OUTLINES  OF  PSYCHIATRY. 

How,  for  example,  can  one  possibly  conceive  that  the  specially 
acquired  manual  dexterity  of  the  graver  could  by  any  process  be 
so  impressed  upon  the  sex  cells  that  it  would  reappear  in  the 
offspring?  These  cells  have  no  intimate  relation  with  the  several 
parts  of  the  body.  They  are  relegated  to  a  corner,  so  to  speak, 
and  the  only  general  relations  in  which  they  come  with  the  rest 
of  the  body  result  from  the  fact  that  they  are  bathed  and  nour- 
ished in  the  body  fluids.  The  only  thing  we  can  conceive  of  as 
being  inherited  is  the  particular  make-up  of  the  individual  that 
made  the  acquirement  of  the  trait  possible. 

Although  the  sex  cells  have  not  that  intimate  direct  connection 
with  the  different  parts  of  the  body  by  means  of  nerve  currents 
that  would  make  it  possible  for  a  change  occurring  anywhere  to 
be  reflected  in  them,  they  are  bathed  in  and  nourished  by  the  body 
fluids  and  we  might  expect  that  general  conditions  producing 
toxaemia  might  so  affect  them  as  in  some  way  to  impair  their 
functions  as  shown  in  the  resulting  offspring. 

Such  appears  to  be  the  case,  so  that  as  a  matter  of  fact  we  find 
not  infrequently  various  debilitating  and  toxic  conditions  in  the 
parents,  the  most  common  of  which  are  probably  tuberculosis, 
alcoholism,  and  syphilis.  General  conditions  of  this  sort  impair 
the  germ  plasm  and  produce  defects  in  development  as  a  result. 

There  are  reasons,  however,  for  combating  this  view.  Cells, 
no  matter  where  found,  may  be  distorted  in  their  development  by 
poisons.  But  as  soon  as  the  distributing  factor  is  removed  they 
bound  back  to  their  type.  Even  though  puny  children  may  be 
born  to  drunken  parents  we  might  expect  them  to  develop  all  right 
under  a  favorable  environment,  but  if  they  do  not  it  is  as  logical 
to  explain  the  results  as  following  because  they  are  born  of  the 
same  germ  plasm,  and  therefore  have  the  same  tendencies  as 
their  parents  which  led,  among  other  things,  to  their  drunken- 
ness, as  it  is  to  explain  them  as  a  result  of  the  poisoning  of  the 
germ  cell.^ 

This  view  of  the  non-inheritance  of  acquired  characters  has 
come  about  largely  as  a  reaction  against  the  extreme  Lamarckian 
position.  Now,  however,  there  is  a  tendency  to  return  to  the 
previous  position  but  in  a  somewhat  modified  form.     The  sex 

3  Reid,  G.  Archdall :  The  Laws  of  Heredity.  London,  Methuen,  &  Co., 
1910. 


CAUSES   OF   MENTAL  DISORDERS.  33 

cells  are  undoubtedly  much  more  highly  differentiated  than  orig- 
inally supposed  but  yet  not  to  the  extent  of  being  the  carriers  of 
the  finer  individual  adjustments  acquired  in  the  lifetime  of  the 
individual :  Acquired  characters  are  perhaps  inherited  in  this  new 
sense  namely,  only  when  they  have  been  in  evidence  long  enough, 
have  a  sufficiently  long  history,  to  have  become  essential,  they 
are  then  relegated,  so  to  speak,  to  the  sex  cells  when  they  become 
permanently  fixed. 

We  can  see  how  this  lack  of  transmission  of  acquired  traits  in 
this  newer  sense  is  really  constructively  conservative.  The  prog- 
ress of  the  race  has  been  one  of  infinite  slowness,  by  a  process  of 
blind  right  and  wrong  trials.  If  every  acquired  trait  were  in- 
herited, every  wild  idea  propagated,  the  confusion  of  tendencies 
would  multiply  to  no  good.  This,  however,  is  not  the  case. 
Every  departure  from  the  mean  tends  to  be  wiped  out  in  accord- 
ance with  Galton's  law  of  filial  regression.  The  fundamental  is 
preserved  while  the  variations  tend  to  disappear.  In  this  way  the 
race  is  kept,  as  a  whole,  at  the  point  of  highest  average  efficiency 
although,  of  course,  as  is  nature's  way,  often  at  the  sacrifice  of 
the  individual.  And  so  the  progress  has  been  slow  and  laborious 
but,  and  here  lies  the  compensation,  correspondingly  sure,  and 
permanent. 

Thus  it  would  seem,  that  like  the  soul  of  the  theologian,  the 
germ  plasm  takes  up  its  habitation  in  the  body.  The  body  grows, 
develops,  dies.  The  germ  plasm  is  relatively  undisturbed  and 
transmits  to  the  next  generation  what  it  received  from  the  last 
uninfluenced  by  passing  changes  that  may  have  taken  place  in  the 
body  where  it  for  the  time  being  resided.  This  body  has  only 
such  general  effects  upon  the  germ  plasm,  as  to  the  character  of 
being  it  will  produce  in  the  next  generation,  as  are  fundamental 
and  racially  significant,  except  such  effects  as  are  produced  as  the 
result  of  general  disturbances  of  metabolism,  toxemias  and  infec- 
tions, which  impair  the  body  fluids,  and  the  immediate  chemical 
and  physical  environment  of  the  sex  cells.  These  effects  are 
general  effects,  however,  and  it  is  quite  unthinkable  that  the  effect 
in  the  next  generation  should  be  a  reproduction  of  like  condi- 
tions. These  effects  show  themselves  rather  in  general  disturb- 
ances of  development,  oftener  in  the  line  of  deficiency.  This 
apparent  unchangeable  character  of  the  germ  plasm  is  at  the  basis 


34  OUTLINES  OF   PSYCHIATRY. 

of  the  assumed  lack  of  inheritance  of  acquired  characters  and  has 
given  rise  to  the  phrase  the  "  continuity  of  the  germ  plasm." 

While,  therefore,  we  not  infrequently  do  find  the  same  disease 
developing  in  the  children  that  the  parents  suffered  from — the 
heredity  is  similar — it  happens  more  frequently  that  general  con- 
ditions of  ill  health  in  the  ascendants  have  so  impaired  the  germ 
plasm  as  to  produce  conditions  of  instability  which  may  show 
itself  in  various  ways  other  than  in  reflecting  the  same  disease — 
the  heredity  is  dissimliar. 

The  dangers  supposed  to  lie  in  the  marriages  of  near  relatives 
are  largely  fictitious.*  Ireland  in  a  review  of  this  subject  states 
that  it  has  not  been  shown  that  such  marriages  have  a  higher 
percentage  of  evil  results  than  is  found  in  the  results  of  mar- 
riages throughout  the  entire  population.  The  real  danger  lies  in 
the  possibility  of  bringing  together  two  persons  both  of  whom 
have  the  same  bad  strain  and  thus  emphasizing  the  bad  effects. 

Acquiring  Predisposition. — The  two  most  important  agents  in 
bringing  about  an  acquired  predisposition  to  mental  derangement 
are  alcohol  and  syphilis,  while  tuberculosis  from  the  prolonged 
toxic-exhaustive  condition  it  brings  about  would  probably  come 
third.  All  of  these  causes,  the  first  two  especially,  may  by  acting 
upon  the  normal  brain  bring  about  such  changes  as  to  predispose 
it  to  disease  and  thus  predispose  the  individual  to  the  develop- 
ment of  mental  disorder.  It  must  not  be  forgotten,  too,  that  the 
occurrence  of  one  attack  of  mental  disorder  predisposes  to  subse- 
quent attacks. 

General:  Age. — According  to  the  Eleventh  Census  there  is  a 
gradual  increase  in  the  number  of  cases  of  mental  disease  from 
the  age  of  lo  to  the  age  of  40.  From  40  on  there  is  a  gradual 
decrease.  The  table  given  is  very  interesting  and  worth  repro- 
ducing.    It  is  as  follows : 

It  would  appear  from  this  table  that  the  greatest  liability  to 
mental  disease  existed  between  the  ages  of  30  and  40  as  it  is 
between  these  ages  that  we  find  the  largest  number  of  the  insane. 
That  so  many  more  mentally  ill  should  be  between  thirty  and 
forty  years  or  age  than  in  any  other  decade  is  simply  due  to  the 
fact  that  there  are  more  people  in  the  general  community  living 

*  Ireland,  William  W. :  The  Mental  Affections  of  Children,  Idiocy,  Im- 
becility and  Insanity.    London  and  Edinburgh,  1898. 


CAUSES  OF   MENTAL  DISORDERS. 


35 


Age  Period 

Age  Period 

When  Insanity 

1890. 

1880. 

When  Insanity 

1890. 

1900. 

Appeared, 

Appeared. 

lo-is 

39 

227 

55-60 

4.316 

940 

15-20 

790 

2,417 

60-65 

3.261 

652 

20-^5 

3.138 

5.450 

65-70 

2,066 

358 

25-30 

S.704 

S.926 

70-75 

1.343 

186 

30-35 

8.123 

5.492 

75-80 

632 

90 

35-40 

8,182 

4.321 

80-85 

310 

23 

40-45 

7.930 

3.305 

85-90 

102 

8 

45-50 

7.287 

2.405 

90-95 

38 

3 

50-55 

6,036 

1.542 

95    + 

3 

of  this  age.  Considering  the  number  of  the  mentally  sick  in  each 
decade  compared  to  the  total  population  of  the  same  age,  it  will 
be  found  that  the  liability  to  such  disorders  practically  progres- 
sively increases  from  twenty  to  eighty  years  of  age.  Phelps' 
published  an  interesting  table  illustrating  this  point  based  upon 
the  population  of  Minnesota. 

Column  4  is  obtained  by  multiplying  Column  3  by  1,000,000 
and  dividing  by  Column  2.  It  is  from  the  proportion :  "  807,978 
is  to  54,  as  1,000,000  is  to  the  required  number." 

Column  5  is  obtained  by  dividing  the  chances  per  million  of 

Comparative  Liability  to  Insanity  in  Each  Decade. 


Age  by  Decades. 


No.  Living  in 

Each  Age 

in  Minn. 

(Census,  1900). 


No.  Insane 

Admitted 

in  Minn. 

inigoi-1902, 


No.  Insane  of  Each 

Age  Decade 

Admitted  in  Minn. 

per  Million  People 

Living  at  that 

Age  in  Minn. 


Proportionate 
Chance  of  Becom- 
ing Insane  at  Each 
Age  Decade,  as 
Compared  with 
Other  Decades,  in 
Percentages, 


Under  age  20  .  . 
From  age  20-30 
From  age  30-40 
From  age  40-50 
From  age  50-60 
From  age  60-70 
From  age  70-80 
Over  80 

Total 


807,978 

309,281 

252,248 

172,688 

103,189 

63.388 

31,026 

7.494 


54 
380 
522 
379 
218 
122 
78 
31 


66.8 
1.257.7 
2,069.3 
2,194.2 
2,112.6 
1,924.6 
2,514.0 
4.136.6 


.410 
7.727 
12.710 
13-481 
12.980 
11.824 
15-447 
25.415 


1,747,292 

(People 

in  Minn.) 


1.793 


16,275.8 

(Sum  of  relative 

chances.) 


99.994 


each  decade  by  the  total  number  of  chances.  It  merely  gives  the 
chance  of  each  decade  as  compared  with  the  whole  In  terms  of 
parts  of  100.     It  is  a  relative  percentage. 

5  Phelps,  R.   M. :   Certain  Hitherto  Unpublished  Data   Concerning  the 
Insane,  Jour.  A.  M,  A.,  Dec.  11,  1909. 


36 


OUTLINES   OF   PSYCHIATRY. 


The  caution  must  be  added  that  this  last  column  does  not  show 
the  percentage  of  the  mentally  ill  committed,  but  only  the  relative 
chances  of  becoming  so  in  one  decade  as  compared  to  the  other 
decades  and  as  compared  with  one  hundred  chances.  If  there 
were  an  equal  number  of  people  at  each  age,  this  would  be  the 
proportion  committed  from  each  decade. 

It  is  interesting  to  note  at  this  point  that  a  considerable  portion 
of  the  frequently  referred  to  increase  of  insanity  is  due  to  the 
prolongation  of  life  by  preventive  medicine.  More  people  live  to 
become  mentally  diseased.  Dana^  has  called  attention  to  the 
fact  that  while  the  greatest  number  of  the  mentally  ill  are  afflicted 
in  the  decade  from  thirty  to  forty  years,  more  people  are  now  liv- 
ing to  that  age,  the  expectancy  of  life  in  the  United  States  having 
increased  from  28  in  1840  to  34.5  in  1900. 

Physiological  Epochs. — The  periods  of  life  at  which  a  latent 
tendency  to  mental  disorder  may  crop  out  are  the  physiological 
epochs  during  which  there  are  great  changes  going  on  in  the  gen- 
eral nutrition,  physiological  crises  in  fact.  These  physiological 
epochs  are  the  periods  of  puberty  and  adolescence,  the  puerperium, 
the  climacterium,  and  the  senium.  Mental  disease  at  these  phys- 
iological epochs,  excepting  the  senium,  indicates  serious  deficiency 
in  capacity  for  biological  adjustment. 

Sex. — Although  the  psychoses  are  about  equally  divided  between 
the  sexes,  the  specially  dangerous  periods  in  the  female,  the  puer- 
perium and  the  climacterium,  being  about  balanced  by  the  results 
of  alcohol  and  syphilis  and  a  more  strenuous  mental  life  in  the 
male,  yet  the  U.  S.  Census  seems  to  show  a  tendency  to  a  gradual 
increase  in  the  percentage  of  males  as  shown  by  the  following 
table: 


Per  Cent.  Distribution  of 

Sex. 

General  Population. 

Tnsane  Enumeration  in  Hospitals. 

1900. 

1890. 

i88o. 

December 
31,  1903. 

June  I, 
1890. 

June  I, 
1880. 

Both  sexes 

100 

100 

100 

100 

100 

100 

Males 

48.9 

SI-2 
48.8 

50.9 
49.1 

52.3 
47-7 

SI.8 
48.2 

50.4 
49.6 

Females 

^  Dana,  Charles  Loomis :  Psychiatry  in  its  Relation  to  Other  Sciences, 
Trans.  Congress  of  Arts  and  Sciences,  Universal  Exposition,  St.  Louis, 
1904.     Boston  and  New  York,  Houghton,  Mifflin  and  Company,  1906. 


CAUSES   OF    MENTAL  DISORDERS.  37 

Civil  Condition. — The  percentage  of  certifiable  psychoses  is 
greater  in  the  unmarried  than  in  the  married.  The  Census  re- 
turns for  all  these  in  hospitals  in  1904  show  50.1  per  cent,  to  have 
been  single,  leaving  the  balance  of  49.9  per  cent,  to  be  divided 
among  married,  widowed,  divorced  and  unknown. 

Climate. — The  only  effect  of  climate  is  to  supply  conditions 
which  make  exhaustion  and  infection  more  liable.  The  climate 
itself  has  no  direct  effect.  Malaria,  yellow  fever,  and  other  dis- 
eases of  tropical  climates  produce  a  condition  of  toxaemia  and 
exhaustion  favorable  to  the  outcrop  of  mental  diseases,  while  the 
extreme  heat  makes  physical  exertion  more  exhausting  and  the 
effects  of  alcohol  are  not  so  well  borne. 

Civilisation. — It  has  generally  been  supposed  that  mental  illness 
is  most  prevalent  among  the  most  highly  civilized.  In  the  process 
of  evolution  the  struggle  for  existence  has  changed  from  a  phys- 
ical to  a  mental  struggle  and  as  it  is  the  organ  most  used  that 
is  most  open  to  the  dangers  of  accident  and  disease  so  it  might 
be  supposed  that  the  brain  would  give  way  more  frequently  as  the 
stresses  of  life  become  more  and  more  mental  rather  than  physical. 
This  general  proposition  is  open  to  contention,  especially  as  we 
know  so  little  about  primitive  races  from  this  point  of  view.  At 
least  it  does  not  take  into  consideration  the  compensations  offered 
by  civilization.  The  fact  that  civilization  requires  so  much  suc- 
cessful repression  would  seem  to  imply,  however,  that  the  psy- 
choses, which  are  due  so  largely  to  failure  of  repression,  must  be 
expected  to  be  much  more  prevalent  the  higher  the  civilization. 

Exciting  Causes. 

Predisposition  alone,  however,  is  not  sufficient  to  produce 
mental  disorder,  especially  is  this  true  of  an  acquired  predis- 
position such  as  that  induced  by  alcohol,  syphilis,  and  tuberculosis, 
without  the  element  of  mental  stress  added.  This  is  well  illus- 
trated by  the  condition  of  the  American  Indian.  Sorely  afflicted 
as  he  is  by  the  diseases  and  vices  of  civilization,  his  tendency  is  to 
an  outdoor  life,  and  as  his  land  has  disappeared  and  he  has  become 
physically  incapacitated,  the  government  has  supported  him,  so 
that  his  sufferings  have  been  in  the  main  physical  and  not  mental. 
Careless,  solvenly,  and  improvident,  he  does  not  know  much  of 
worry  for  the  morrow,  and  so  we  rarely  find  psychoses  in  his  race. 


38  OUTLINES   OF   PSYCHIATRY. 

Physical:  Toxic. — The  various  poisons  which  may  act  as  excit- 
ing causes  of  the  psychoses  may  be  either  exogenous — coming 
from  without — or  endogenous — originating  within  the  body.  Of 
the  exogenous  variety  alcohol  is  perhaps  the  most  prominent.  It 
is  apparently  responsible  for  from  fifteen  to  twenty  per  cent,  of 
cases  in  males  (see  Chapter  XIV).  Alcohol  and  syphilis  together, 
if  we  include  paresis  as  a  syphihtic  disease,  are  responsible  for 
fully  twenty  per  cent,  of  the  certifiable  psychoses  in  males  at  least. 
Some  of  the  other  poisons  that  belong  in  this  group  are  opium 
(morphine),  cocaine,  atropine  and  its  isomers,  lead,  and  mercury, 
while  the  toxins  of  various  diseases,  such  as  syphilis,  tuberculosis, 
typhoid,  yellow  fever,  malaria,  and  influenza  frequently  act  as  ex- 
citing causes.  Of  the  endogenous  poisons  the  most  important  are 
those  which  originate  from  the  gastro-intestinal  tract,  and  as  a 
result  of  chronic  nephritis.  The  mental  disorders  which  accom- 
pany such  diseases  as  myxedema,  exophthalmic  goitre,  and 
acromegaly  probably  belong  here  also. 

Traumatic. — Direct  injuries  to  the  head,  such  as  bullet  wounds 
and  fracture,  are,  of  course,  not  infrequently  the  immediate  causes 
of  mental  disorder,  while  more  indirect  injuries,  such  as  concus- 
sion from  falls,  transmitted  perhaps  through  the  spine,  may  also 
be  the  starting  point  of  a  psychosis. 

Exhaustion. — Exhaustion  from  prolonged  physical  and  mental 
strain,  from  chronic  diseases,  or  as  the  result  of  acute  conditions 
following  fever,  or  the  result  of  sudden  loss  of  considerable 
blood,  may  be  prominent  exciting  causes.  It  is  to  be  remembered 
in  this  connection  that  exhaustion,  especially  physical,  results  in 
and  may  in  large  part  produce  its  effects  by  the  development 
of  toxic  substances,  as  for  instance  from  the  breaking  down  of 
muscle. 

Bodily  Diseases. — Bodily  diseases  other  than  those  developing 
poisons  may  act  as  causes  by  disturbances  of  circulation,  reflex 
irritation,  disturbances  of  nutrition  and  exhaustion.  Such  are 
cardiac  diseases  with  broken  compensation,  the  reflex  irritation 
from  intestinal  parasites,  and  the  various  nervous  diseases  which 
often  have  mental  symptoms  connected  with  them,  such  as  epi- 
lepsy, Huntington's  chorea,  hysteria. 

Mental. — Any  severe  mental  stress  may  act  as  an  exciting  cause. 
A  sudden  emotional  shock,  such  as  fright,  or  the  horror  resulting 


CAUSES   OF   MENTAL  DISORDERS.  39 

from  the  terrible  sights  of  the  wounded  and  dying  in  a  railroad 
wreck,  may  induce  an  outbreak  of  mental  disorder,  while  the  less 
acute  conditions  of  worry  and  anxiety,  usually  acting  over  a  con- 
siderable period  of  time,  may  also  be  etiological  factors  in  the 
development  of  a  psychosis. 

The  whole  subject  of  mental  causes  has  received  a  great  deal 
of  attention  of  late'^  and  has  constituted  a  sort  of  reaction  from 
the  pathologist's  viewpoint.  Reference  to  the  discussion  of  mind 
as  an  adaptive  mechanism  will  make  it  clear  how  failure  on  the 
part  of  the  individual  to  get  into  harmonious  adjustment  with  his 
environment  may  produce  a  psychosis. 

'^  White:  Mechanisms  of  Character  Formation.    New  York,  The  Mac- 
millan  Company,  1916. 


CHAPTER  VI. 

Treatment. 

In  the  treatment  of  the  psychoses  the  general  principles  of 
therapeutics  are  of  course  applicable  as  in  other  departments  of 
medicine.  Disorders  of  various  organs  are  found  among  the 
psychotic  as  among  the  sane  and  require  the  same  sort  of  treat- 
ment. It  is  only  intended  in  this  chapter  to  devote  a  few  words 
to  the  discussion  of  the  therapeutics  of  the  psychoses  in  so  far 
as  it  differs  from  therapeutics  as  ordinarily  resorted  to,  for  there 
are  conditions  commonly  met  with  among  them  that  require 
treatment  that  are  rare  or  absent  elsewhere.  Excitement, 
agitation  and  violence,  for  example,  may  occur  in  the  delirium  of 
fever  but  is  of  short  duration — transitory — while  in  the  realm  of 
mental  disease  these  conditions  may  persist  for  weeks  and  require 
treatment.  Only  certain  general  considerations  will  be  taken  up 
here,  while  special  matters  pertaining  to  the  different  psychoses 
will  be  discussed  in  their  appropriate  places. 

Hydrotherapy. — It  is  impracticable  here  to  take  up  a  full  dis- 
cussion of  this  subject.  The  student  should  consult  special  works 
for  detailed  information.  It  may  be  said,  however,  that  the  vari- 
ous forms  of  hydrotherapeutic  devices  form  one  of  the  more 
valuable  of  the  additions  to  the  means  of  treatment.  This 
is  true  especially  of  the  treatment  of  the  excitements.  In  the 
absence  of  hydrotherapy  the  only  way  to  deal  with  these  cases 
is  by  manual  of  mechanical  restraint,  or  by  chemical  restraint. 
All  of  these  means  are  undesirable  if  avoidable.  With  a  well 
equipped  hydrotherapeutic  outfit,  however,  their  use  may  be  re- 
duced to  a  minimum. 

Such  an  equipment  would  provide  for  the  giving  of  hot  baths — 
local  or  general :  full  baths,  simple  or  medicated,  at  various  tem- 
peratures: needle,  rain,  fan,  spray,  jet,  spinal  and  Scotch  douches, 
regulated  as  to  temperature  and  pressure :  wet  packs,  hot  or  cold : 
sitz  baths,  etc. 

These  various  measures  have  eliminating,  stimulating,  or  seda- 


TREATMENT. 


41 


tive  effects,  according  to  circumstances.  For  toxic  states,  such 
as  chronic  alcohohsm,  the  stimulating  effect  of  the  hot  air  with 
profuse  sweating,  followed  by  the  stimulating  effects  of  the 
Scotch  douche,  are  very  valuable,  while  in  excited  cases  some 
form  of  wet  pack  gives  better  results.  In  applying  the  wet  pack 
the  wet  sheet  is  put  on  first  after  being  sufficiently  wrung  out, 
usually  of  cold  water,  so  as  not  to  drip,  carefully  wrapped  about 
the  patient  and  tucked  in,  then  a  dry  blanket  is  rolled  about  the 
patient  and  also  carefully  tucked  in  at  the  arms,  made  snug  at 
the  neck,  and  turned  in  at  the  foot,  so  that  no  draft  can  strike 
any  portion  of  the  wet  body  and  neither  arm  nor  leg  can  be  volun- 
tarily exposed  by  the  patient.  When  skilfully  applied  it  affords 
a  sufficient  restraint  to  the  patient  until  the  sedative  effect  is  mani- 
fest. Excited  patients  treated  in  this  way  with  a  cold  cloth  or  ice 
cap  to  the  head  often  quiet  down  surprisingly  and  not  infrequently 
go  to  sleep.  The  great  advantage  of  this  method  is  that  it  can 
be  used  in  the  home. 

The  warm  bath  of  a  few  minutes'  duration  is  also  a  very  valu- 
able sedative  that  can  be  used  at  home,  but  if  used  care  should  be 
taken  to  watch  the  heart  if  the  patient  is  weak  and  when  the 
bath  is  over  the  patient  should  be  rapidly  wiped  off,  wrapped 
up  in  blankets  and  put  to  bed  without  any  exposure  to  drafts  or 
cooling. 

Continuous  Bath. — ^The  continuous  bath  is  used  for  the  most 
part  in  the  treatment  of  the  active  and  excited  cases.  The  tub 
is  made  somewhat  longer  than  usual  to  accommodate  the  patient 
at  full  length  comfortably.  The  patient  is  placed  in  the  tub  (if 
desired  he  may  rest  in  a  canvas  hammock  attached  to  the  sides), 
the  water  being  kept  by  means  of  a  regulating  apparatus  at  from 
95°  to  97°  F.  The  bath  may  be  prolonged  for  several  hours;  in 
fact  the  patient  may  spend  all  day  in  the  bath.  In  Germany, 
where  this  form  of  treatment  originated,  the  patients  are  often 
kept  continuously  in  the  bath  not  only  for  hours  but  for  days 
and  weeks  at  a  time,  eating  and  sleeping  there.  It  is  remarkable 
that  many  of  these  disturbed  cases  seem  after  a  time  to  like  the 
warm  sedative  influence  of  the  water,  and  I  have  seen  a  patient 
cry  to  go  back  in  the  tub  after  she  had  been  taken  out. 

Another  great  advantage  of  the  continuous  bath  is  the  good 
eft'ect  the  water  has  upon  the  skin.  The  warm  water  keeps  it 
4 


42  OUTLINES  OF   PSYCHIATRY. 

soft  and  active  and  the  tendency  which  exists  in  so  many  cases, 
particularly  of  paresis,  to  the  development  of  bed-sores  is  largely 
prevented;  the  patient  resting  in  a  medium  of  considerably  higher 
specific  gravity  than  the  air  a  large  proportion  of  the  pressure  is 
thus  removed  from  the  skin,  so  moderating  one  of  the  most  promi- 
nent causes. 

Refusal  of  Food. — This  is  one  of  the  most  annoying  symptoms 
met  with  and  yet  is  quite  common  among  the  depressed  cases. 
It  frequently  has  a  serious  influence  upon  the  health  of  the  pa- 
tient, so  it  becomes  of  the  highest  importance  to  know  how  to 
meet  it. 

If  the  patient  be  in  good  physical  condition  it  is  wise  to  let 
him  go  for  a  time  without  food  in  the  hope  that  the  cravings 
of  hunger  will  force  him  to  eat,  as  once  artificial  feeding  is  begun 
it  is  liable  to  have  to  be  continued.  A  strong,  vigorous  patient 
may  be  permitted  to  fast  thus  for  as  long  as  three  days,  while 
on  the  other  hand,  it  frequently  happens  that  when  the  patient  is 
first  seen  he  has  already  been  temporized  with  so  long  that  he 
is  in  such  condition  as  to  require  feeding  at  once. 

There  are  many  methods  of  artificial  feeding,  but  the  method 
of  tube-feeding  is  the  only  one  that  merits  much  attention.  This 
method  may  be  employed  either  by  the  nasal  or  the  esophageal 
route. 

The  esophageal  route  is  always  to  be  preferred.  The  patient 
is  fed  sitting  up  in  a  firmly  construced,  straight-backed  arm- 
chair, unless  a  greatly  enfeebled  condition  renders  the  position 
on  the  back  imperative.  The  operator  stands  behind  and  gently 
forces  the  mouth  open  with  a  soft  wooden  wedge  introduced  on 
the  left  side,  then  with  the  patient's  head  held  under  his  left  arm 
he  holds  the  wedge  with  his  left  hand,  which  is  steadied  by  plac- 
ing his  little  finger  under  the  patient's  chin.  The  patient's  head 
thus  secured,  the  arms  and  legs  held  by  nurses,  if  necessary,  the 
esophageal  tube  is  dipped  in  the  milk  to  be  given  and  passed.  A 
funnel,  preferably  vulcanized  rubber,  is  now  inserted  in  the  tube 
by  a  nurse  and  the  food  slowly  poured  in. 

The  same  position  is  assumed  for  passing  the  nasal  tube.  The 
tube  used  may  be  an  ordinary  male  catheter.  Before  attempting 
to  pass  it  it  is  well  to  examine  the  nose,  particularly  for  polypi  and 
deflected  septum,  and  choose  the  side  which  will  present  the  least 


TREATMENT.  43 

obstruction.  The  tube  then  being  dipped  in  the  milk  to  lubricate 
it  it  is  passed  along  the  floor  of  the  nostril  and  down  into  the 
esophagus.  Care  must  be  taken  to  see  that  it  does  not  enter  the 
larynx.  If  it  should,  the  usual  signs  are  severe  strangling,  cough- 
ing and  cyanosis,  while  the  air  may  be  heard  making  a  rushing 
sound  as  it  passes  in  and  out  of  the  tube.  It  must  not  be  for- 
gotten, however,  that  in  some  cases,  particularly  in  paresis,  there 
is  more  or  less  anesthesia  of  the  larynx  and  these  signs  may  be 
in  large  measure  absent.  It  is  well,  therefore,  after  the  tube  is 
passed  to  wait  a  few  moments  and  see  if  the  patient  does  respire 
through  it,  not  forgetting  that  immediately  after  it  first  enters 
the  esophagus  a  little  rush  of  gas  may  escape  through  it  from 
the  stomach.  The  tube  being  passed,  the  food  may  be  introduced 
through  a  funnel  by  gravity,  as  with  the  esophageal  tube,  but  as 
this  is  a  very  slow  process,  owing  to  the  small  calibre  of  the  tube, 
it  is  more  satisfactory  to  attach  a  Davidson  syringe,  first  filling 
it  with  milk,  so  as  not  to  inject  air,  and  then  gradually  pump  the 
food  through  this. 

In  withdrawing  the  tube  it  should  be  pinched  tightly  to  prevent 
a  leakage  as  the  end  passes  over  the  larynx. 

The  nasal  tube  is  preferable  particularly  with  those  patients 
who  resist  very  actively  and  who  have  a  good  set  of  teeth  that 
the  introduction  of  the  wedge  may  injure.  It  is  contra-indicated 
in  cases  of  nasal  disease  and  obstruction,  while  it  is  best  to  avoid 
its  use  if  possible  when  there  is  anesthesia  of  the  larynx. 

The  esophageal  tube  should  be  avoided  when  there  is  disease 
of  the  esophagus  or  cardia  and  in  some  cases  of  feeble  heart  action 
when  the  nasal  tube  can  be  passed  with  less  commotion. 

The  usual  mixture  for  feeding  is  a  pint  to  a  pint  and  a  half 
of  milk  to  which  is  added  two  eggs.  In  addition  there  may  be 
added  beef  juices  or  other  forms  of  liquid  food  and  various  medi- 
cines, particularly  cathartics  and  hypnotics  with  the  evening 
feeding. 

Feeding  should  be  done  at  least  twice  daily — morning  and 
evening.  If  the  food  is  not  well  digested  oftener  and  in  smaller 
amounts. 

Medication. — As  the  various  psychoses  are  for  the  most  part 
relatively  chronic  diseases,  great  care  should  be  used  in  prescrib- 
ing opium  or  any  of  its  alkaloids,  as  otherwise  a  serious  addiction 
may  be  encouraged. 


44  OUTLINES   OF   PSYCHIATRY. 

One  of  the  most  frequent  conditions  which  has  to  be  met  by 
drugs  is  insomnia.  This  is  a  symptom  in  many  of  the  psychoses 
and  often  over  a  considerable  period  of  time.  Of  the  various 
hypnotics  paraldehyde  is  one  of  the  best,  but  of  course  is  greatly 
limited  in  its  use  because  of  its  very  disagreeable  odor  and  taste. 
Sulfonal  is  an  excellent  hypnotic,  but  somewhat  slow  in  its  action. 
It  is  best  given  at  supper  time  and  then  will  be  active  about  bed 
time.  It  may  be  given  to  patients  who  refuse  medicine  by  mixing 
with  apple  sauce,  for  example,  as  it  has  little  taste.  Its  prolonged 
use  should  be  avoided,  as  poisoning  may  occur  with  hematopor- 
phyrinuria.  Trional  is  equally  as  good  a  hypnotic  and  acts  more 
promptly.  In  some  cases  in  which  the  patient  wakes  up  in  the 
small  hours  of  the  morning  a  mixture  of  sulfonal  and  trional  may 
be  given,  about  15  grs.  each,  at  bed  time.  The  trional  will  act 
the  early  part  of  the  night  and  the  sulfonal  the  latter.  Veronal 
acts  similarly  and  may  be  given  in  from  5  to  10  or  perhaps  15  gr. 
doses.  Chloralamid  is  a  similar  drug  and  may  be  given  in  a 
pleasant  elixir,  while  in  some  more  troublesome  cases  chloral  may 
be  indicated. 

In  the  use  of  hypnotics  care  should  be  taken  to  interrupt  the 
administration  from  time  to  time  to  see  if  normal  sleep  will  not 
supervene  and  also  to  change  from  one  to  the  other  to  prevent 
cumulative  effects  or  addiction.  It  is  of  course  understood  that 
hypnotics  should  be  restored  to  only  when  other  means  have 
failed. 

In  the  acutely  excited  conditions  requiring  sedatives  jibout  the 
only  drugs  that  are  efficient  are  the  alkaloids  of  hyoscyamus,  given 
hypodermically.  Great  care  should  be  exercised  in  using  this 
drug,  as  the  various  preparations  are  somewhat  uncertain.  The 
chemically  pure  alkaloids  have  not  been  so  successful  in  my  hands 
as  the  amorphous  sulphate  of  hyoscyamine  (Merck),  which  con- 
tains a  mixture  of  the  alkaloids.  This  drug  may  be  given  hypo- 
dermically in  doses  as  high  as  Yio  g^-,  or  in  a  strong,  vigorous 
person  without  cardio-vascular  disease,  Yg  gr.  Its  action  seems  to 
be  assisted  by  3  or  4  gtts.  of  Magendie's  solution.  It  must  be 
remembered  that  the  pure  alkaloids  must  not  be  administered  in 
any  such  doses — usually  not  over  ^oo-%o  gf-  Too  small  doses 
of  the  drug  may  not  quiet  the  patient  at  all,  but  on  the  other  hand 
only  produce  a  degree  of  belladonna  delirium. 


TREATMENT.  45 

Here,  as  with  the  hypnotics,  drugs  should  not  be  used  until 
other  means  have  failed. 

In  regard  to  the  whole  subject  of  the  giving  of  drugs,  too  much 
emphasis  cannot  be  placed  on  the  caution  to  avoid  over-medica- 
tion. It  is  not  an  uncommon  thing  to  see  patients  admitted  to 
a  hospital  suffering  from  the  toxic  effects  of  drugs,  usually  bro- 
mides and  chloral.  In  this  condition  they  not  only  suffer  the 
deleterious  effects  of  the  toxemia,  but  the  symptoms  of  the  disease 
from  which  they  are  suffering  may  be  hopelessly  clouded. 

Psychotherapy. — It  is,  of  course,  quite  impossible  in  the  limits 
of  a  work  of  this  sort  to  discuss  in  a  manner  at  all  adequate  the 
subject  of  psychotherapy.  The  literature  of  the  subject  has 
become  very  extensive  in  recent  years  and  I  think  needlessly 
complicated,  particularly  as  a  result  of  the  growing  understand- 
ing and  appreciation  of  the  psychogenic  factors  in  the  etiology 
and  symptomatology  of  the  psychoses.  The  simple  thing  to  re- 
member is  that  in  mental  disorders  that  are  due  to  mental  causes 
something  may  be  expected  from  a  direct  appeal  to  the  mental 
conditions  as  a  result  of  which  the  symptoms  developed. 

The  human  soul  is  filled  with  desires,  vague  longings,  Teach- 
ings out,  and  in  its  effort  to  bring  about  a  state  of  contentment, 
of  satisfaction,  often  becomes  hopelessly  involved  in  attempts  at 
adjustments  to  conditions  which  are  quite  impossible.  The  failure 
is  felt  keenly  but  the  true  cause  is  unknown.  It  is  for  the  physi- 
cian, after  following  the  difficulties  and  intricacies,  to  take  the 
patient  frankly  into  his  confidence  and  by  pointing  out  the  exact 
mechanism  of  his  distress,  by  putting  his  finger  accurately  on  the 
difficulty,  so  give  the  patient  his  opportunity  to  meet  the  problem 
in  an  efficient  way. 

Psychoanalysis.^ — The  conception  appears  to  be  general  that 
psychotherapy  is  summed  up  and  included  in  suggestion.  Aside 
from  the  fact  that  no  one  seems  to  have  a  very  clear  idea  of  just 
what  suggestion  really  is  this  conception  ignores  the  recent  work 
that  has  been  done  along  these  lines.  Suggestion  really  plays  on 
the  surface.  The  fundamental,  underlying  conditions  are  not 
reached  by  suggestion.  These  underlying  conditions  which  pro- 
duce the  symptomatology  of  the  psychoneuroses  are  the  same  con- 

1  White :  Mechanisms  of  Character  Formation.  New  York,  The  Mac- 
millan  Co.,  1916. 


4^  OUTLINES   OF   PSYCHIATRY. 

ditions  that  make  suggestion  possible.  The  accepted  suggestion 
is  quite  as  much  a  pathological  product  as  the  various  symptoms 
themselves. 

When  we  have  a  case  that  we  have  decided  to  try  psychoanal- 
ysis with,  the  first  thing  to  do  is  to  have  a  detailed  talk  with  the 
patient  covering  the  manifestations  of  the  disorder  and  also  touch- 
ing the  main  events  of  the  entire  life  so  far  as  possible.  We  must 
remember  that  the  symptoms  with  which  we  have  to  deal  are  only 
end  products — the  results  perhaps  of  a  mechanism  that  seems 
fairly  simple  but  in  the  last  analysis  they  are  results  made  possible 
by  all  that  has  gone  before — the  entire  psychic  life  of  the  indi- 
vidual. Our  initial  talk,  therefore,  serves  not  only  to  give  us  an 
account  of  the  symptoms  but  to  orient  us  with  regard  to  the  gen- 
eral make-up  of  the  personality  with  which  we  have  to  deal. 

During  the  course  of  this  conversation  it  is  inevitable  that  cer- 
tain points  will  stand  out  as  being  important  to  pursue  further. 
Here  begins  the  real  problem  of  psychoanalysis. 

The  method  of  procedure,  the  so-called  method  of  free  associa- 
tion, is  roughly  as  follows :  The  patient  needs  to  be  alone  with  the 
physician  in  a  room  as  far  as  possible  from  distracting  influences 
— noises,  bright  lights,  etc.  To  this  end,  too,  the  patient  should  be 
disposed  as  comfortably  as  possible  so  that  physical  discomfort 
or  uneasiness  will  not  interfere.  It  is  well  to  have  the  eyes  closed 
also,  so  that  distractions  from  the  visual  field  may  be  eliminated 
so  far  as  possible.  This  general  state  of  quiescence  and  passivity 
can  be  enhanced  by  having  him  observe  some  monotonous  sen- 
sory stimulus  that  dominates  the  sensorium  and  shuts  out  less 
insistent  and  inconsiderable  sensations,  such  as  the  buzzing  of  a 
faradic  coil.  In  this  condition  the  particular  feature  in  the  his- 
tory that  it  is  desired  to  pursue  further  is  presented  to  the  patient 
and  he  is  asked  to  hold  that  event  before  his  mind,  to  make  no 
mental  effort  of  any  sort,  such  for  instance  as  trying  to  remember, 
but  to  tell  absolutely  every  thought  that  comes  to  his  mind,  no 
matter  how  fleeting,  no  matter  how  inconsequential  it  may  seem 
or  no  matter  how  little  bearing  it  may  appear  to  have  on  the  ques- 
tion at  issue. 

The  theory  of  this  procedure  is  that  if  the  patient  does  not 
direct  the  thought  in  any  way  every  idea  that  comes  must  of 
necessity  have  some  relation  to  the  event  held  before  the  mind 


TREATMENT.  4/ 

about  which  enhghtenment  is  sought.  The  monotonous  sensory 
conditions  are  observed  to  prevent  distracting  influences  from 
outside  sources.  The  directions  to  the  patient  if  carried  out  pre- 
vent distractions  from  inside  sources. 

It  is  difficult  to  secure  this  condition  of  passivity  in  many  cases, 
especially  those  who  have  never  consciously  used  their  minds  and 
therefore  do  not  know  how  to  comply  with  the  directions.  It  is 
difficult  to  get  the  patients  to  tell  all  the  ideas  that  come.  They 
naturally  refrain  from  mentioning  those  that  appear  to  be  entirely 
fortuitous  and  to  have  nothing  to  do  with  the  case.  It  will  be 
seen  from  the  theory,  however,  that  these  cannot  be  unimportant. 
They  must  bear  some  relation  to  the  central  event. 

This  is  the  method  of  attack  to  fill  out  the  information  acquired 
in  the  initial  conversation.  The  symptoms  should  all  be  dealt 
with  in  this  way  for  the  purpose  of  uncovering  the  submerged 
complexes  and  disclosing  their  mechanisms.  As  we  proceed  new 
events  will  constantly  be  brought  to  light  that  must  also  be  pur- 
sued, as  must  also  all  the  significant  events  of  the  patient's  life. 

We  must  never  forget,  too,  to  investigate  the  dream  life. 
Freud  has  shown  that  the  mechanism  of  dreams  is  quite  the  same 
as  that  of  the  symptoms,  so  we  may  expect  to  get  valuable  infor- 
mation from  this  realm.  The  method  of  procedure  is  the  same. 
The  patient  quite  likely  will  deny  dreaming  at  all  at  first  but  pur- 
suit of  the  inquiry  may  very  well  disclose  a  rich  dream  life. 

Nothing  is  too  trivial  to  be  worthy  of  analysis,  nothing  but  may 
throw  light  upon  the  situation.  All  the  little  slips  of  the  tongue, 
forgotten  incidents,  points  at  which  two  recitals  of  an  occurrence 
do  not  agree,  even  witticisms  are  necessary  to  trace  out,  while  the 
dream  life  offers  abundance  of  rich  material  for  study. 

This  is  the  method  of  unraveling  the  tangled  network  of  mental 
life.  It  takes  weeks,  months,  perhaps  years  of  constant  effort. 
There  is  no  royal  road,  no  short  cut  to  results.  What  it  has  taken 
a  life  time  to  produce  cannot  be  laid  aside  in  an  hour.  How  dif- 
ferent a  conception  dominates  this  method  of  procedure  from  that 
of  the  method  of  suggestion ! 

At  times  in  the  course  of  the  analysis  it  seems  as  though  no 
further  progress  were  possible.  At  these  points,  and  perhaps  also 
to  start  with  just  after  the  initial  conversation,  it  is  well  to  try 
some  word  associations.    This  is  done  by  taking  the  reactions  to  a 


48  OUTLINES   OF   PSYCHIATRY. 

list  (see  Chapter  VII)  of  say  one  hundred  words  carefully  chosen 
to  cover  the  ordinary  field  of  the  average  person's  possibilities  of 
complex  formation.  There  may  be  distributed  through  this  list 
words  that  for  some  reason  may  be  supposed  to  have  significance. 

The  method  of  procedure  is  to  read  the  words  to  the  patient, 
instructing  him  to  answer  immediately  the  first  word  or  thought 
that  comes  to  his  mind  after  hearing  the  word  read,  and  recording 
the  time  it  takes  for  this  reaction.  The  most  practical  way  for 
recording  the  time  is  by  a  stop-watch  graduated  to  fifths  of  a 
second.  After  the  list  has  been  completed  it  is  repeated  in  the 
same  way;  the  time  need  not  be  recorded,  however,  except  that 
the  patient  is  asked  to  repeat  the  same  associations  he  gave  the 
first  time  if  he  can  recall  them. 

When  one  of  the  words  in  the  list  touches  a  complex,  is  a 
complex  indicator,  a  marked  disturbance  in  the  reaction  is  noted. 
This  disturbance  shows  in  several  ways :  increased  length  of  time ; 
peculiarity  of  the  type  of  reaction  ;  failure  to  repeat  the  same  asso- 
ciation ;  and  irradiation  of  the  disturbance  to  the  next  one  or  two 
associations. 

It  will  probably  occur  to  many  to  wonder  how  it  is  that  we  can 
expect  to  find  memories  reaching  back  for  years  sufficiently  well 
preserved  to  be  helpful.  As  a  matter  of  fact  the  memories  of  all 
repressed  experiences  are  perfectly  clear  no  matter  how  old.  The 
explanation  for  this  is  that  being  repressed  they  are  dissociated 
from  the  everyday  events  of  life,  they  are  kept  in  their  original 
form,  they  have  not  been  subjected  to  the  attrition  and  amalgama- 
tion with  the  intricacies  of  associational  life.  They  do  not  fade 
out  by  this  process  of  absorption  as  do  the  memories  of  indiflFerent 
events,  but  remain  where  ever  after  they  may  be  brought  to  light 
by  analysis  and  used  as  helps  for  cure. 

It  will  be  seen  from  this  short  description  what  a  far-reaching 
method  this  is.  A  method  of  analysis  from  which  no  event  of 
life,  no  matter  how  apparently  trivial,  is  free.  A  method  that  in 
its  results  lays  bare  not  only  the  immediate  antecedents  and  causes 
of  the  symptoms,  but  the  whole  innermost  life  of  the  patient, 
reaching  back  even  to  the  period  of  early  childhood.  This  of 
course  takes  time.  A  case  of  any  complexity  and  difficulty  quite 
generally  takes  several  months,  of  at  least  two  or  three  seances 
each  week,  to  reach  a  final  result. 

This  element  of  time  is  an  important  one  for  more  than  one 


TREATMENT.  49 

reason.  In  the  first  place  it  may,  and  does,  largely  preclude  the 
possibility  of  the  general  use  of  this  method  by  the  average  prac- 
titioner. It  should  not,  however,  lead  to  adverse  and  destructive 
criticism  of  the  method  for  that  reason  alone,  as  it  has  done  in 
some  instances.  If  the  psychology  upon  which  the  method  is 
based  is  true,  we  must  of  necessity  accept  it  whether  it  meets 
with  our  convenience  or  not.  Then  it  is  rather  silly  after  all  to 
have  a  scientific  position  condemned  because  to  carry  out  the 
resulting  methods  takes  too  much  time.  An  effort  might  legiti- 
mately be  made  to  improve  upon  the  method  but  truth  does  not 
yield  to  attack  based  upon  such  principles. 

There  is  some  reason  to  believe,  however,  that  the  time  needed 
to  effect  lasting  results  in  this  class  of  cases  cannot  be  materially 
shortened.  The  cases  of  psychoneurosis  come  to  us  in  a  sea  of 
trouble,  tossing  about  on  waves  of  emotion,  far  from  shore  and 
safety,  blind  and  hopeless,  resigned  often  to  a  life  of  suffering, 
desperate  often  at  seeing  no  hope  of  release,  but  quite  unable  to 
help  themselves  at  all.  Of  course  in  the  nature  of  the  case  the 
real  troubles,  the  buried  complexes  not  only  are  not  known  by  the 
patient,  but  they  cannot  be  known  and  the  obvious  explanations 
for  the  symptoms,  that  the  patient  often  has  ready  at  hand,  not 
only  are  not  the  real  explanations,  but  they  cannot  be.  Neverthe- 
less, the  original  repressions  and  the  dissociations  in  conscious- 
ness resulting  are  quite  characteristically  due  to  a  false  attitude 
towards  the  problems  of  life.  The  young  woman  in  love  with 
some  one  of  whom  the  father  disapproves  may  have  a  fleeting 
thought  that  the  father's  death  would  straighten  matters  out  and 
enable  her  to  marry  without  further  opposition.  Now  instead  of 
reacting  to  such  a  thought  naturally  by  realizing  that  as  a  con- 
scious human  being  such  a  thought  was  merely  an  expression  of 
her  wish  to  marry  the  man  she  loved  and  an  expression  of  a 
natural  desire  that  the  obstacles  in  the  way  be  removed,  and  put- 
ting it  quietly  and  without  passion  of  consideration  as  impossible 
because  of  its  unethical  character,  in  fact  unworthy  of  even  con- 
templation, she  becomes  terribly  horrified  that  such  a  thought 
could  even  find  entrance  to  her  mind  and  represses  it  immediately 
as  not  only  too  terrible  for  consideration  but  with  a  sense  of 
chagrin,  shame,  self-reproach.  Such  a  putting  aside,  side-track- 
ing of  a  disagreeable  thought,  such  a  refusal  to  meet  an  unwel- 
come quest  in  the  open,  frankly,  such  a  refusal  to  even  see  the 


50  OUTLINES   OF   PSYCHIATRY. 

disagreeable  does  not  make  for  efficient  reaction,  does  not  enable 
the  individual  to  adequately  adjust. 

These  patients  come  with  no  adequate  philosophy  of  life,  no 
raft  with  which  they  can  safely  reach  shore  in  their  sea  of  trouble. 
They  have  narrow,  distorted,  perverted  viewpoints  and  these  it  is 
necessary  to  fully  appreciate  in  the  course  of  the  analysis,  for 
these  must  be  corrected.  They  cannot  be  corrected  by  a  pronun- 
ciamento,  by  laying  down  what  the  analyzer  believes  to  be  the  law 
and  the  gospel  on  the  different  questions  involved  but  must  be 
slowly  changed  by  a  process  of  reeducation  in  which  the  person- 
ality of  the  physician  and  his  attitude  towards  the  whole  situation 
plays  a  prominent  part.  And  herein  lies  the  importance  of  the 
element  of  time. 

This  reeducation  of  the  patient  is  dependent  perhaps  more  upon 
the  attitude  of  the  physician  than  upon  any  particular  thing  he 
may  say.  The  personality  of  the  physician  plays  a  certain  role. 
Whereas  theoretically  his  personality  should  be  nil  in  its  effects 
if  the  method  were  accurate,  still  the  method  is  not  perfect  and 
has  to  be  carried  out  by  human  means.  The  patient,  before  the 
analysis  has  proceeded  far,  sees  that  to  go  on  means  to  bare  his 
very  soul.  One  does  not  confess  his  innermost  thoughts  to  every 
one,  the  hysteric,  for  example,  is  not  impelled  to  unburden  him- 
self of  his  story  to  the  passerby,  like  the  ancient  mariner.  Quite 
the  contrary.  Tlie  whole  trend  of  his  malady  is  toward  conceal- 
ment, repression.  The  personal  characteristics  of  the  physician 
do,  I  think,  play  some  part,  although  I  am  willing  to  admit  that 
this  part  may  be  less  in  proportion  to  the  perfection  of  the  method. 

Now  as  to  the  physician's  attitude.  In  the  first  place  his  atti- 
tude should  be  one  of  absolute  lack  of  critique.  The  physician 
is  merely  after  facts,  for  by  the  analysis  he  hopes  to  help  the 
patient  by  removing  the  symptoms.  He  will  in  the  course  of  his 
analysis  hear  many  intimate  thoughts,  learn  of  many  wrong,  per- 
haps disgusting,  or  even  criminal  acts.  He  should  express  no 
surprise.  They  are  but  facts,  that  is  all.  The  patient  must  not 
be  blamed  or  laughed  at.  He  has  already  done  that  for  himself 
many  times.  In  fact  that  is  often  the  trouble.  Self-blame  may 
have  been  the  cause  for  the  original  repression.  His  moral  sense 
is  already  keen,  in  fact  perhaps  too  keen,  and  an  element  of 
prudery  or  over-scrupulousness  must  be  removed  for  a  more 
healthy  attitude  of  mind. 


TREATMENT.  5 1 

Sympathy  is  likewise  not  to  be  indulged  in.  The  patient  does 
not  want  it  and  it  is  not  helpful.  The  attitude  of  the  physician, 
however,  has  as  an  element  the  most  important  factor  in  sym- 
pathy— understanding.  To  be  understood  is  indeed  a  privilege. 
For  years  the  psychoneurotic  has  failed  of  being  understood,  has 
refrained  from  talking  to  persons  about  himself,  perhaps  after 
one  or  two  disagreeable  experiences,  for  fear  of  being  laughed 
at.  In  fact,  he  has  failed  to  understand  himself.  Now  to  find 
some  one  who  does  understand^ — what  a  relief ! — and  it  is  helpful 
in  no  small  degree  in  the  progress  of  the  work. 

It  is  these  elements  in  the  attitude  of  the  physician — his  lack 
of  critique  and  his  understanding — that  are  the  quiet  determinants 
making  through  the  weeks  and  months  of  psychoanalysis  for  a 
more  wholesome,  a  more  robust  philosophy  of  life,  and  finally 
when  all  the  submerged  complexes  and  mechanisms  of  the  symp- 
toms have  been  uncovered  our  patient  emerges  literally  born 
again.  The  disordered  material  which  the  patient  brought  to  us 
has,  if  we  have  been,  successful,  been  sorted  over,  rearranged, 
added  to,  and  built  into  a  new  and  an  enduring  structure. 

Prophylaxis. — It  is  to  be  hoped  that  some  day  we  shall  have 
a  sufficient  understanding  of  character  to  be  able  to  pick  out  those 
types  liable  to  develop  psychoses  and  to  protect  them  from  that 
class  of  stresses  that  they  are  least  able  to  withstand.  At  pres- 
ent we  can  hardly  be  said  to  approximate  to  this.  The  neurotic 
child,  however,  can  be  recognized  and  should  be  safeguarded, 
especially  throughout  school  life  and  the  period  of  puberty  and 
adolescence.  Some  day,  perhaps,  competent  advice  will  be  sought 
by  parents  as  to  the  best  methods  to  be  employed  in  the  rearing 
of  their  children.  Until  then  we  are  largely  helpless  in  the  matter 
of  prevention. 

With  the  advance  in  the  study  of  the  individual  psychology  of 
the  psychoses  many  psychogenic  etiological  factors  have  been  un- 
covered which  ofTer  considerable  hope  for  the  future  of  prophy- 
laxis in  this  branch  of  medicine.  Certainly  a  careful  study  of 
cases  which  have  recovered  will  often  indicate  clearly  the  things 
to  avoid  in  order  to  prevent  another  breakdown.^ 

2  For  a  discussion  of  institution  care  and  various  problems,  social  and 
other,  of  the  mentally  ill  see  White:  The  Principles  of  Mental  Hygiene. 
New  York,  The  Macmillan  Co.,  1917. 


CHAPTER   VII. 


General  Symptomatology. 

In  describing  the  general  symptoms  of  the  psychoses  the  scheme 
of  the  several  mental  processes  outlined  in  the  preceding  chapters 
will  be  adhered  to  and  the  principal  disorders  of  each  taken  up 
in  turn.     Certain  symptoms,  however,  associated  more  particu- 

INTRAPSYCHIC 


S=  SENSORr    PROJECTION    FlELD 

M"  MOTOR      PROJE  CTION    FIELD 

A^  INITIAL     IDEA 

Z»  TERMINAL    IDEA 

Fig.  2.     Showing  subdivisions  of  mental  processes. 


larly  with  special  psychoses  will  be  left  and  discussed  in  the  chap- 
ter in  which  that  particular  psychosis  is  described. 

Before  going  on  to  the  discussion  of  the  special  symptoms  it 
may  be  well  first  to  call  attention  to  a  slight  modification  of  the 
diagram  used  previously  to  illustrate  the  mental  processes  for 

52 


GENERAL   SYMPTOMATOLOGY.  53 

the   purpose   of   illustrating   some  general   principles   involved. 
(See  Fig.  2.) 

In  this  diagram  everything  from  6"  to  M,  inclusive,  is  included 
in  consciousness,  the  term  used  to  denote  the  sum  total  of  mental 
life.  This  is  indicated  by  the  term  used:  for  example,  psycho- 
motor would  refer  to  motor  acts  originating  in  consciousness. 
A  reflex  act  would  thus  not  be  included — it  is  not  a  psychomotor 
act,  taking  place  entirely  without  the  realm  of  consciousness. 
Taking  then  this  tripartite  division  of  consciousness,  we  may 
follow  Wernicke'^  and  say  that  in  each  of  the  three  territories 
there  may  be  three  types  of  disorder,  as  follows : 

Psychosensory.  Intrapsychic.  Psychomotor. 

Anesthesia.  Afunction.  Akinesis. 

Hyperesthesia.  Hyperfunction.  Hyperkinesis. 

Paresthesia.  Parafunction.  Parakinesis. 

Bearing  these  general  principles  in  mind,  we  will  proceed  now 
to  the  discussion  of  the  special  symptoms. 

Disorders  of  Perception. 

Illusion. — ^An  illusion  is  an  inexact,  or  inaccurate,  perception. 
The  information  conveyed  to  the  mind  by  the  sense  organ  is  mis- 
interpreted, so  that  the  source  of  the  sensory  impressions  in  the 
environment  is  not  appreciated  at  its  true  value.  A  strap  lying 
on  the  floor  may  be  perceived  as  a  snake,  the  sighing  of  the  wind 
may  be  perceived  as  the  whispering  of  a  human  voice,  a  bad  taste 
in  the  mouth  may  be  perceived  as  poison,  and  so  on  throughout 
the  diflferent  sensory  realms.  The  distinguishing  thing  about  an 
illusion  is  that  an  actual  something  in  the  environment  is  perceived 
but  the  perception  is  not  a  correct  one  and  conveys  false  informa- 
tion to  the  mind. 

Hallucination. — An  hallucination,  on  the  other  hand,  is  gen- 
erally conceived  to  be  a  perception  without  sensory  foundation 
in  the  environment.  A  snake  is  seen  on  the  floor  where  there  is 
nothing  which  could  be  mistaken  for  a  snake,  the  floor  is  bare ; 
human  voices  are  heard  where  there  are  actually  no  sounds  in 
the  environment  which  could  be  interpreted  as  such ;  poison  is 
tasted  where  there  has  been  nothing  in  the  food  or  mouth  which 

1  Wernicke:  Grundriss  der  Psychiatric. 


54  OUTLINES   OF  PSYCHIATRY. 

has  given  origin  to  the  taste.  The  distinguishing  feature  of  an 
hallucination  then  is  a  perception  without  there  being  anything 
in  the  environment  to  perceive. 

Recent  studies,  however,  have  made  it  highly  probable  that  a 
large  number  of  what  have  been  supposed  to  be  hallucinations 
are  in  reality  associated  with  pathological,  or  even  at  times  physi- 
ological processes  occurring  in  the  sensory  end  organs,  so  that, 
with  reference  to  the  eye  and  ear,  for  example,  they  might  be  said 
to  be  of  entoptic  or  entotic  origin  respectively. 

So  far,  however,  as  any  given  erroneous  perception  is  con- 
cerned it  really  matters  little  from  the  point  of  view  as  to  its  sig- 
nificance as  a  symptom  of  mental  disease,  whether  it  be  classed  as 
an  illusion  or  an  hallucination.  The  mental  process  in  both  in- 
stances is  identical.  In  practical  use  the  two  are  not  often  dis- 
tinguished, but  false  perceptions  are  generally  spoken  of  as  hallu- 
cinations and  as  the  mental  process  is  the  same  in  both  hallucina- 
tion and  illusion  the  necessity  for  their  distinction  does  not  arise 
and  the  use  of  the  term  hallucination  serves  the  purpose  very  well. 

Using  the  term  hallucination  then  to  include  the  phenomena  of 
illusion,  there  are  a  number  of  considerations  to  take  up  regard- 
ing their  different  forms  and  their  manifestations  in  the  various 
sensory  areas. 

Pseudo -hallucinations. — Pseudo-hallucinations,  also  called  psy- 
chic and  apperception  hallucinations,  seem  to  occupy  a  position 
midway  between  imagination  and  the  fully  developed  form  of 
hallucination.  The  patient  does  not  have  the  same  conviction  of 
their  external  reality  and  may  even  appreciate  their  subjective 
nature  while  still  believing  them  to  be  brought  about  by  external 
agencies,  i.  e.,  God  or  his  enemies — as  in  the  case  cited  by 
Kandinsky^  of  the  patient  who  had  a  pseudo-hallucination  of  a 
lion  which  appeared  to  him  and  laid  its  forepaws  on  his  shoulder. 
The  patient  appreciated  that  he  saw  the  lion  only  with  his  mind's 
eye  and  was  not  afraid  as  he  otherwise  would  have  been,  and 
interpreted  the  vision  as  signifying  his  allegiance  to  England. 

Pseudo-hallucination  differs  from  imagination  in  the  fact  that 
the  sensory  elements  have  a  greater  objectivity  and  occur  inde- 

2  Kandinsky,  V. :  Kritische  u.  klinische  Betrachtungen  im  Gebiete  d. 
Sinnestiiuschungen  (1885),  p.  42,  cited  by  James,  William:  The  Principles 
of  Psychology,  Vol.  II,  New  York,  Henry  Holt  &  Co.,  1890. 


GENERAL   SYMPTOMATOLOGY.  55 

pendently  of  the  volition  of  the  subject.  They,  in  general,  differ 
from  hallucinations  in  having  somewhat  less  objective  reality 
and  further  are  more  often  in  consistent  harmony  with  the  con- 
tent of  consciousness — do  not  obtrude  themselves  suddenly  and 
unexpectedly  into  the  field  of  consciousness  as  hallucinations 
often  do,  particularly  auditory  hallucinations.  They  not  infre- 
quently involve  two  or  more  sensor}'-  areas  and  constitute  an  ele- 
ment in  the  so-called  dream  states. 

Hypnagogic  Hallucinations. — These  are  hallucinations  which 
occur  in  the  intermediate  state  between  sleeping  and  waking. 
Their  principal  importance  for  us  lies  in  the  fact  that  they  may 
readily  be  mistaken  for  hallucinations  occurring  in  the  waking 
state.  If  the  possibility  of  confusion  is  kept  in  mind  the  differen- 
tiation can  easily  be  made  without  trouble.  The  following  case 
illustrates  this  condition  and  the  principles  of  differentiation : 

The  patient,  a  middle-aged  man,  claims  to  have  numerous  visions.  He 
has  been  a  spiritualist  for  years  and  often  sees  visions  of  deceased  per- 
sons. He  describes  one  occurrence  when  he  had  a  vision  as  follows : 
"  I  went  into  the  cellarway  to  fill  my  lamp,  and  after  filling  the  lamp  I 
saw  the  road  from  Catherine  Holliday's  north  to  the  county  line.  There 
was  no  significance  attached  to  that,  but  I  sat  there  and  presently  I  saw 
a  hand ;  a  chubby  kind  of  fleshy  hand  and  the  finger  nail  was  grown  down 
over  the  end  of  the  front  finger  a  little  over  a  quarter  of  an  inch  wide, 
but  it  grew  clear  over  the  end  of  the  finger.  I  said  that  is  a  funny  finger, 
and  I  sat  a  second  more  and  I  heard  the  words,  Ezra  Perkins,  and  I  says, 
'  why,  I  know  Ezra  Perkins.'  Presently  all  was  changed  and  I  saw  a 
house,  door  opening  to  the  east.  In  one  room  was  a  ground  floor  and  a 
wood  bench;  then  I  saw  a  small  room  with  a  painted  floor,  painted  yel- 
low, a  small  bedstead  with  no  banister  or  curtains  around ;  on  the  edge 
of  the  bed  I  saw  a  small  manila  cord  or  rope.  Then  I  looked  as  though 
I  were  passing  by  buildings  and  I  saw  a  house.  On  the  north  part  of  the 
building  the  blinds  seemed  to  be  red  and  dark ;  the  south  part  was  green 
and  there  were  flowers  in  the  windows.  Then  I  saw  Hiram  Brinsmead 
apparently  coming  out  to  the  road.  Then  I  saw  a  small  boy  with  light 
hair.  Then  I  saw  the  interior  of  a  room  on  the  east  side  of  the  house, 
a  lady  reclining  on  the  bed  bolstered  up  on  some  pillows.  She  lay 
quartering  across  the  bed  from  the  southeast  to  northwest.  She  had  a 
pink  dress  on,  made  plain  with  the  exception  of  a  ruffle  or  goring  piece 
around  the  sleeves  and  the  same  around  the  skirt  bound  around  with 
white,  and  was  reading  the  Bible. 

"  That  is  all  there  is  of  that  only  it  is  imperfect,  but  it  is  worded  just 
as  I  can  recall  it." 


56  OUTLINES   OF  PSYCHIATRY. 

This  description  bears  on  its  face  certain  evidences  of  the  dream 
state.  The  sudden  shifting  of  the  scene  and  the  following-  of  one 
event  upon  another  without  any  apparent  reason  for  the  associa- 
tion is  characteristic  of  dreams.  Further  than  this,  it  is  to  be 
noted  that  the  surroundings  were  favorable  to  sleep.  The  per- 
cipient starts  to  fill  his  lamp  during  the  latter  part  of  the  after- 
noon, he  sits  down  on  the  landing  after  it  is  done  (this  would 
indicate  that  he  must  have  been  tired).  He  is  sitting  in  this  posi- 
tion when  the  visions  appear.  He  must  have  sat  there,  at  his  own 
estimation,  for  about  twenty  minutes,  for  when  he  arose  he  saw 
it  was  just  getting  dark  and  it  was  quite  light  when  he  sat  down. 
It  is  also  noteworthy  in  this  case  that  descriptions  of  visions  taken 
at  considerable  intervals  vary  considerably  and  this  variation  is 
most  marked  in  the  direction  of  forget  fulness,  the  later  descrip- 
tions showing  a  tendency  to  omit  many  of  the  facts  contained  in 
the  former,  although  there  is  also  a  tendency  to  include  certain 
other  instances  not  at  first  mentioned.  This  latter  tendency  is, 
however,  not  so  marked.  The  former  tendency  is  quite  charac- 
teristic of  dreams,  as  any  one  can  testify  to  his  own  satisfaction 
who  has  ever  had  occasion  to  recall  a  dream.  A  dream  which  on 
awakening  in  the  morning  may  be  quite  well  remembered,  is  in 
the  course  of  a  few  days  or  even  hours  quite  hazy  in  its  outlines, 
if  no  efforts  have  been  made  in  the  meantime  to  recall  it.  The 
latter  tendency  is  equally  characteristic  of  amnesic  states  generally. 

In  addition  to  the  above  reason  for  considering  these  visions 
as  having  occurred  in  a  dream  state  of  consciousness,  the  per- 
cipient states  that  at  one  time,  while  describing  these  same  visions, 
that  after  they  had  passed  he  arose  and  stretched  himself,  a  very 
common  evidence  of  having  been  asleep.  He  denied  this,  how- 
ever, afterwards.  He  also  describes  one  other  vision  after  which 
he  had  a  "  sort  of  tired  feeling"  for  a  minute  or  two  which,  how- 
ever, soon  passed  away. 

Auditory  Hallucinations. — When  these  are  elementary,  that  is, 
are  largely  sensory  in  character  with  few  associations,  they  are 
known  as  akoasms.  Such  would  be  simple  sounds,  as  buzzing, 
crackling,  ringing,  and  the  like.  The  more  complicated  halluci- 
nations which  are  conceived  by  the  patient  to  be  "  voices  " — ver- 
bal auditory  hallucinations — are  known  as  phonemes. 


GENERAL   SYMPTOMATOLOGY.  57 

The  "  voices "  say  pleasant  or  unpleasant  things  but  usually 
the  character  of  the  remarks  are  consistent  throughout  and  in 
harmony  with  the  general  mental  condition  of  the  patient.  They 
may  be  heard  in  both  ears  or  in  only  one  ear  and  be  of  any  timbre. 
Rarely  different  voices  are  heard  in  the  two  ears,  as  in  one  of  my 
patients  who  heard  Christ  talking  to  her  in  her  right  ear  and  the 
Devil  in  her  left.  The  "  voices  "  may  be  located  externally  or  on 
the  contrary  be  heard  coming  from  different  parts  of  the  body, 
i.  e.,  the  "  epigastric  voice."  Sometimes  the  patients,  when  closely 
questioned,  will  say  that  they  do  not  hear  any  sound,  any  spoken 
word,  but  as  described  by  one  of  my  hallucinated  cases,  "  it  was 
more  as  if  they  conversed  with  her  directly  through  her  mind." 

More  obscure  conditions  are  those  in  which  the  patient  believes 
that  his  thoughts  become  audible,  that  he  can  hear  his  thoughts 
before  he  can  speak  them. 

In  patients  suffering  from  auditory  hallucinations,  ear  disease 
resulting  in  various  degrees  of  deafness  is  common. 

Visual  Hallucinations. — Elementary  hallucinations,  in  which 
the  sensory  element  is  maximal  and  the  associational  element  mim- 
mal — photomata — occur  as  flashes  of  Hght,  sparks,  colors,  and  the 
like.  All  degrees  of  elaboration  occur  from  these  simple  condi- 
tions to  the  most  complex  visions.  Hallucinations  of  sight  are 
more  apt  to  be  pleasant  than  those  of  hearing,  but  they  too  are 
frequently  disagreeable,  often  terrifying,  as  visions  of  hell  and  of 
all  sorts  of  noxious  creatures  so  common  in  the  various  deliria. 
Visual  hallucinations  occur  not  infrequently  in  the  blind. 

Hallucinations  of  Taste  and  Smell. — Hallucinations  of  these 
two  senses  are  quite  apt  to  be  associated  and  are  almost  uniformly 
disagreeable,  as  in  one  of  my  cases,  a  middle-aged  woman,  who 
claimed  she  smelled  and  tasted  the  blood  of  people  who  were 
killed  in  the  hospital.  The  blood  was  smelled  when  the  meals 
were  being  cooked  and  tasted  at  meal  time  in  the  food.  Poison  is 
frequently  complained  of  as  being  tasted  in  the  food  and  noxious 
and  poisonous  vapors  are  often  smelled. 

Haptic  Hallucinations. — The  various  special  senses  located  in 
the  skin — ^touch,  pain,  heat  and  cold — may  be  the  subject  of  hallu- 
cinations. The  most  common  are  indefinite  disturbances  of  the 
nature  of  paresthesia,  hallucinations  of  animals  crawling  over  the 
skin  (deliria),  or  under  the  skin,  particularly  at  the  finger  tips 


58  OUTLINES   OF  PSYCHIATRY. 

(cocainism) .  Hallucinations  of  touch  are  not  uncommon,  but 
are  usually  associated  with  other  disorders  of  perception. 

Hallucinations  of  the  Organic  Sensations. — The  most  common 
of  these  are  peculiar  and  often  indescribable  sensations  coming 
from  the  internal  organs  and  giving  rise  to  such  beliefs  as:  the 
bones  are  broken,  the  brain  dried  up,  an  immense  tapeworm  is 
coiled  up  in  the  lungs,  the  bowels  are  stopped  up,  there  is  no 
stomach,  and  the  like. 

Disturbances  in  the  realm  of  the  sexual  sensations  also  belong 
tmder  this  head  and  lead  to  such  ideas  in  women  as  that  they  are 
violated  while  they  sleep,  and  in  men  that  their  organs  are  abused 
and  their  semen  drawn  off. 

Kinesthetic  or  Motor  Hallucinations. — These  are  sensations  of 
movement  of  some  sort.  The  sensations  from  muscles,  joints 
the  tendons  may  be  involved,  as  may  also  the  static  sense,  owing 
to  labyrinthine  disturbance.  Disturbance  in  these  sensory  areas 
give  rise  to  hallucinations  leading  to  the  belief  that  the  body  has 
undergone  a  change  in  position.  One  patient  complained  that 
men  came  to  her  room  nights,  carried  her  away,  subjected  her  to 
improper  and  indecent  treatment  and  then  brought  her  back. 

A  more  common  motor  hallucination  is  the  verbal  motor  hallu- 
cination. Patients  who  complain  that  their  thoughts  are  audible 
may  be  brought  to  this  belief  by  feeling  their  lips  move  as  in 
speech,  and  inferring  that  they  are  involuntarily  speaking  or  being 
made  to  speak. 

Reflex  Hallucinations. — This  variety  of  hallucination  is  based 
upon  secondary  sensations  which  are  sensations  arising  in  one 
sensory  field  when  the  stimulus  has  been  applied  in  another  sen- 
sory field.  Thus  stimulation  of  the  eye  may  produce  sensations 
of  sound,  stimulation  of  the  taste  bulbs  may  produce  odors,  etc., 
etc.    The  following  cases  illustrate  these  conditions : 

Mrs.  J.,  set.  25  years,  in  good  general  health,  complains  of  naso-pharj^n- 
geal  catarrh  and  tickling  throat,  causing  cough.  She  has  deflected  septum 
and  enlarged  lingual  tonsils.  Operation  upon  these  and  subsequent  appli- 
cation of  ordinary  styptics  have  been  accompanied  by  the  odor  of  almonds 
located  on  the  side  of  the  nose. 

Mrs.  B.,  set.  28  years,  complains  of  having  a  bad  odor  in  her  breath 
which  seems  most  acute  to  her  in  her  nose.  Her  friends  tell  her  that 
they  cannot  detect  any  unpleasant  odor.  She  seeks  special  medical  advice 
because    she   appreciates    this    odor    and    suspects    friends    of    being   too 


GENERAL   SYMPTOMATOLOGY.  59 

courteous  to  tell  her  of  it.  She  is  in  good  general  health  with  a  slight 
hacking  cough  and  a  tendency  to  clear  her  throat. 

Examination  shows  the  nose  to  be  in  normal  condition  throughout,  the 
nasal  vaults  are  unusually  accessible,  thus  leaving  no  doubt  as  to  their 
healthy  condition.     Pharynx  and  larynx  normal. 

The  nostrils  were  alternately  plugged,  the  lips  closed  and  air  from  each 
nostril  and  the  mouth  tested  separately.  Not  the  slightest  odor  could  be 
detected,  though  she  appreciated  it  herself  as  being  very  disagreeable. 
Two  small  lingual  tonsils  were  more  closely  examined  and  upon  the 
posterior  side  of  each  a  minute  morsel  of  food  was  found.  This  was 
removed,  but  on  examination  was  found  to  have  absolutely  no  odor.  It 
had  not  undergone  sufficient  change  to  disguise  its  character — it  was 
bread.  Shortly  after  its  removal  the  bad  odor  grew  less.  Both  tonsils 
were  at  once  removed  and  the  patient  sent  home.  At  the  end  of  two 
days  all  odor  had  disappeared.  At  the  end  of  four  days  there  was  still 
no  odor,  but  it  was  induced  by  touching  the  neighborhood  of  the  tonsils 
by  a  small  pledget  of  cotton  carrying  a  weak  solution  of  citric  acid.  At 
another  time  it  was  induced  by  a  very  weak  faradic  current.  The  odor 
had  not  reappeared  at  the  end  of  six  weeks  except  by  stimulating  the  taste 
goblets,  and  the  patient  was  entirely  relieved  of  the  hacking  cough. 

This  latter  case  was  truly  hallucinated  by  a  secondary  sensation, 
although  she  v^as  not  psychotic.  It  can  readily  be  seen,  however, 
how  such  a  phenomenon  occurring  in  a  predisposed  individual  or 
in  one  already  over  the  border  line  might  soon  form  the  focus  of 
well-marked  persecutory  delusions. 

The  phenomena  of  secondary  sensations,  the  so-called  sound 
photisms,  light  phonisms,  pain  photisms,  etc.,  have  been  known 
for  a  long  time  and  are  not  particularly  infrequent.  Bleuler 
and  Lehmann^  found  them  present  in  one  form  or  another  in 
seventy-six  persons  out  of  a  total  of  five  hundred  and  ninety- 
six,  t.  e.,  twelve  and  one  half  per  cent.  In  most  all  of  these 
cases,  however,  that  have  come  to  my  attention,  the  primary  and 
secondary  perceptions  are  both  present  in  consciousness,  and  the 
patient  usually  has  no  serious  difficulty  in  distinguishing  the  false 
percention. 

The  following  case,  however,  will  illustrate  how  these  second- 
ary sensations  may  become  true  hallucinations : 

D.  C,  a  young  woman  admitted  to  the  hospital  with  an  acute  psychosis 
of  the  confusional  type  with  dream-like  hallucinations,  both  visual  and 
auditory.    She   saw   all   sorts   of  visual   images,   processions   of   soldiers 

3  Cited  by  Hyslop,  Theo.  B. :  Mental  Physiology.  Philadelphia,  P. 
Blakiston's  Son  &  Co.,  1895. 


6o  OUTLINES   OF   PSYCHIATRY. 

and  the  like,  and  also  heard  voices.  After  recovery  said  that  the  figures 
she  saw  were  in  motion  and  the  principal  direction  of  their  motion  was 
downward,  so  that  she  had  to  strain  to  keep  them  up  in  the  visual  field; 
also  saw  patches  of  light  which  moved  by  preference  to  the  right. 

Examination  shows  vision  20-20  for  both  eyes,  with  slight  astigmatism 
and  slight  photophobia,  with  somewhat  abnormally  red  retinal  reflex. 
Septum  slightly  deflected  to  left  into  middle  meatus.  Right  middle  turbi- 
nated, is  bulbous  and  impinging  on  septum.  There  is  a  sub-acute  catarrhal 
naso-pharyngitis,  probably  following  diphtheria,  which  she  had  had  three 
times.  Ears  show  slight  retraction  of  drum  membrane  with  slightly 
shortened  cone  of  light  in  each  side. 

Stimulation  of  the  retina  by  having  patient  look  at  light  of  an  Argand 
burner  produced  sound  as  of  ringing  bells,  which  lasted  forty-two  seconds 
after  the  light  was  turned  off  and  eyes  shut.  In  trying  this  experiment 
again  the  sound  developed  in  twenty-seven  seconds  after  the  stimulus  was 
applied,  and  had  ceased  in  twenty-two  seconds  after  it  was  withdrawn. 

In  this  case  the  motions  of  the  visions  would  indicate  that  they 
were  due  to  muscse  voHtantes.  Particularly  is  this  indicated  by 
the  effort  required  to  keep  the  images  within  the  visual  field. 
There  is  present,  however,  a  well-marked  catarrhal  condition  of 
the  pharynx,  with  abnormalities  of  the  septum  and  right  middle 
turbinated  which  have  resulted  in  a  moderate  grade  of  middle  ear 
disease.     There  are  also  present  on  experimentation  light  phonisms. 

The  sensory  falsifications  probably  took  their  origin  in  the 
extremely  sensitive  eye  from  the  misinterpretation  of  floating 
bodies  in  the  vitreous,  the  patient  seeing  these  bodies  against  the 
light  walls  and  ceiling  of  the  room  as  she  lay  upon  her  back. 
The  constant  stimulation  of  these  sensitive  eyes  brought  a!bout 
the  light  phonisms  which  were  interpreted  as  voices,  the  auditory 
apparatus  being  in  an  especially  susceptible  state,  due  to  the  sum- 
mation of  stimuli  from  the  abnormal  end  organ. 

Many  kinds  of  secondary  sensations  have  been  described,  any 
one  of  which  may  quite  possibly  give  rise  in  a  disordered  mind 
to  hallucinations,  thus  not  only  sound  photisms,  light  phonisms 
and  similar  combinations  in  the  regions  of  the  special  senses  are 
known,  but  the  more  obscure  region  of  the  coenesthesis  is  some- 
times involved,  and  Gruber  has  described  colored  temperature, 
colored  movement,  colored  resistance,  movement  hearing,  temper- 
ature hearing,  resistance  hearing  and  many  other  combinations 
equally  complicated. 

While  the  pathological  state  of  a  sense  organ  may  indicate  why 


GENERAL  SYMPTOMATOLOGY.  6 1 

it  was,  chosen,  so  to  speak,  to  hallucinate  with  only  psychoanalysis 
can  determine  the  meaning  of  the  hallucination  in  psychological 
terms.  Thus  the  visual  hallucinations  of  the  blind  are  dependent 
upon  a  fundamental  wish  to  be  able  to  see.  The  particular  form 
they  take  is  of  course  more  individually  determined. 

Clouding  of  Consciousness. — The  process  of  perception,  as 
we  have  seen,  is  dependent  upon  sensations  coming  from  with- 
out, which,  however,  must  be  of  sufficient  strength  to  force  their 
way  into  consciousness  and  wake  up,  as  it  were,  the  remains  of 
former  sensations  with  which  they  become  associated.  If  sensory 
stimuli  have  not  this  strength  they  may  be  said  to  be  inadequate. 
We  are  constantly  beset  on  all  sides  by  such  inadequate  stimuli. 
The  presence  of  my  clothes  on  the  different  parts  of  the  body 
ordinarily  causes  no  appreciable  sensations  and  thus  gives  rise  to 
no  perceptions.  The  many  trifling  noises  going  on  about  me 
while  I  am  absorbed  in  writing  these  lines  are  not  heard.  The 
strength  of  the  several  sensory  stimuli  is  not  sufficient  to  cross 
the  threshold  of  consciousness,  their  threshold  value,  as  it  is 
called,  is  too  low  to  result  in  perception.  In  various  diseases 
and  conditions  the  threshold  value  of  sensations  is  greatly  altered. 
This  is  very  marked  in  certain  of  the  deliria,  for  example,  delirium 
tremens.  In  this  disease  we  find  the  patient  wholly  occupied  with 
his  terrifying  visions  and  quite  oblivious  to  the  outside  world  of 
realities.  Loud  sounds  fail  to  attract  his  attention,  the  nurse 
comes  and  goes  without  interrupting  the  course  of  his  delirium. 
Sensory  stimuli  of  ordinary  strength,  or  even  more  than  ordinary 
strength,  fail  to  cross  the  threshold  of  his  consciousness  and  cause 
perception.  If,  however,  the  patient  be  taken  firmly  by  the 
shoulders  and  held  or  even  mildly  shaken  while  a  question  is  prac- 
tically yelled  at  him,  we  may  find  that  he  will  give  a  perfectly 
lucid  and  correct  answer.  The  strength  of  the  sensations  has 
been  sufficiently  increased,  the  resistance  has  been  broken  down, 
perception  takes  place. 

This  condition  of  clouding  of  consciousness  may  exist  in  any 
degree,  from  a  scarcely  noticeable  departure  from  clear  con- 
sciousness to  actual  coma,  and  as  we  can  readily  see  must  be  the 
cause  of  very  imperfect  perceptions  of  the  environment.  Ordi- 
nary stimuli  are  not  appreciated  at  all,  while  those  that  have 
sufficient  force  usually  only  give  rise  to  perceptions  for  the  moment 


62 


OUTLINES   OF  PSYCHIATRY. 


and  are  never  adequately  assimilated.  Thus  we  find  this  condi- 
tion prominently  in  evidence  in  the  various  deliria,  where  it  is 
usually  associated  with  disturbed  affects,  disorders  of  the  train 
of  thought,  and  hallucinations. 

This  can  perhaps  be  better  understood  If  we  will  study  some 
of  the  characteristics  of  consciousness  at  any  given  moment. 
At  such  a  moment  there  are  numerous  sensory  stimuli  which 
have  forced  themselves  over  the  threshold  of  consciousness,  and, 
as  it  were,  are  contending  for  supremacy — for  recognition.  All, 
however,  cannot  be  equally  clearly  recognized,  so  it  comes  that 
one  arouses  clear  perception  while  the  others  are  only  faintly 
perceived.  While  I  am  writing  these  words  the  word  I  am  at  the 
moment  penning  is  perceived  clearly,  while  the  other  words,  the 
books  lying  about  me  on  the  table,  the  striking  of  the  clock  in  the 
adjoining  room,  and  many  other  sensations  are  only  indefinitely, 
hazily  perceived.  The  most  clearly  perceived  sensory  stimuli  are 
said  to  occupy  the  focal  point  of  consciousness,  while  the  other 
sensations  have  only  a  marginal  value.  This  can  be  better  under- 
stood by  reference  to  Fig.  3 — where  the  particular  moment  of 


fi'^CAi. 


THBE9H0L0   OF   COriSciCUS/^CSS 

Fig.  3.    A  wave  of  consciousness. 


consciousness  is  represented  by  a  wave — wave  of  consciousness. 
The  apex  of  the  wave  would  then  be  the  focal  point  of  clearest 
perception,  the  base  of  the  wave  the  threshold  of  consciousness 
and  sensations  crossing  this  threshold  can  be  seen  to  have  any 
degree  of  clearness  as  they  approach  the  focal  point.  The  height 
they  reach  on  the  wave  would  then  be  a  measure  of  their  intensity 
for  that  particular  moment  of  consciousness. 
Dream   States. — This   term   is   applied  to  certain   conditions 


GENERAL   SYMPTOMATOLOGY.  63 

because  of  the  resemblance  they  have  to  conditions  of  dream  con- 
sciousness. The  mind  is  occupied  by  numerous  dreamy  ideas, 
and  usually  also  by  multiform  hallucinations  which  may  take  the 
form  of  visions.  Hallucinations  often  occur  in  more  than  one  of 
the  sensory  territories  contemporaneously,  but  when  this  is  the 
case  they  harmonize  and  are  consistent  with  each  other.  For 
example,  the  patient  who  is  terrified  at  the  flames  she  sees  near  her 
bed,  feels  also  their  heat.  Clouding  may  be  present,  the  threshold 
value  of  sensations  being  raised  so  that  no  impressions  of  ordi- 
nary strength  reach  consciousness,  the  result  being  that  the  patient 
may  be  quite  oblivious  of  his  surroundings.  Unlike  the  normal 
dream  state,  however,  psychomotor  reactions  occur  corresponding 
to  the  content  of  consciousness. 

Disorientation. — Orientation  implies  the  correct  apprehending 
of  the  erivironment,  and  one  is  said  to  be  fully  oriented  when  they 
understand  their  own  position  and  relation  with  reference  to  the 
different  aspects  of  their  environment.  These  aspects  are  three, 
viz. :  temporal,  spatial  and  personal.  Temporal  orientation,  then, 
would  imply  correct  answers  to  such  questions  as,  in  what  year 
were  you  born?  what  year  is  this?  what  day  is  this?  Spatial 
oi'ientation  would  imply  correct  answers  to,  what  city  do  you  live 
in?  on  what  street?  Personal  orientation  would  imply  a  correct 
knowledge  of  who  the  individuals  were  with  whom  the  patient 
came  in  daily  contact,  their  official  positions,  their  names,  etc. 
Disorientation  is  the  reverse  of  this  condition  and  implies  a  lack 
of  apprehension  of  these  three  aspects  of  the  environment  either 
singly  or  together. 

Disorders  of  the  Content  of  Thought. 

Delusion. — A  delusion  is  a  false  belief,  but  as  such  is  not  neces- 
sarily evidence  of  a  psychosis.  Many  false  beliefs  have  no  patho- 
logical significance  whatever.  A  man  may  believe  that  to-day  is 
Thursday  when  in  fact  it  is  Friday.  That  is  a  false  belief  while 
it  lasts,  but  has  only  the  significance  of  a  mistake.  The  belief 
of  certain  savages  that  dreams  represent  the  wanderings  of  their 
disembodied  spirit  we  know  to  be  false,  but  not  an  evidence  of 
mental  disease.  False  beliefs  or  delusions,  then,  may  be  either 
normal  or  abnormal,  and  it  is  for  us  to  endeavor  to  distinguish 
what  constitutes  a  belief  first  as  false  and  then,  as  such,  what 


64  OUTLINES   OF  PSYCHIATRY. 

characterizes  it  as  abnormal.  There  are  three  main  character- 
istics of  delusions  in  general.  First:  they  are  as  a  rule  very 
evidently  not  true  to  facts,  highly  improbable,  even  manifestly 
impossible  often  to  the  extent  of  being  bizarre.  Such,  for  in- 
stance, are  the  delusions  of  great  wealth,  of  royal  lineage,  and 
those  of  a  certain  class  of  patients  who  believe  that  they  have 
no  stomach,  no  brains,  even  that  they  have  no  head.  Second: 
they  cannot  be  corrected  by  an  appeal  to  reason;  not  originating 
in  experience  they  cannot  be  corrected  by  an  appeal  to  experience. 
It  is  impossible  to  argue  the  patient  out  of  his  delusional  beliefs. 
Third:  they  are  out  of  harmony  with  the  individual's  education 
and  surroundings.  The  sick  Fijian  lying  upon  his  back  and 
crying  for  his  soul  to  come  back  to  him  is  but  exemplifying  the 
belief  of  the  race  that  sickness  is  due  to  the  soul,  or  a  part  of  it, 
leaving  the  body.  Should  we  find  a  modern  American,  who  had 
had  the  usual  public  school  advantages,  acting  thus  we  would  be 
justified  in  supposing  him  unbalanced. 

It  sometimes  happens,  however,  that  a  false  belief  does  not 
show  any  of  these  characteristics  and  yet  may  be  pathological. 
A  woman  who  says  her  husband  is  untrue  to  her  has  not  voiced 
a  belief  which  has  on  its  face  any  evidences  of  impossibility, 
and  with  no  knoAvledge  of  the  facts  it  cannot  even  be  said  to 
be  improbable,  and  while  not  susceptible  to  the  test  by  argument, 
it  is  certainly  not  out  of  harmony  with  the  individual's  education 
and  surroundings.  In  such  cases  it  becomes  important  to  study 
the  origin  of  the  belief,  to  find  out  upon  what  sort  of  foundation 
it  is  reared.  If  we  find  that  it  resulted  from  the  patient  having 
awakened  on  several  occasions  during  the  night  and  found  her 
husband's  legs  cold,  and  having  reasoned  from  this  that  he  had 
been  out  of  bed  to  keep  an  appointment  with  his  paramour  in  an 
adjoining  room  we  will  at  once  have  no  difficulty  in  stamping  the 
delusion  as  pathological  because  of  being  founded  upon  and  con- 
structed of  ideas  which  do  not  logically  or  reasonably  lead  to  the 
conclusions  reached. 

Delusions  may  be  classified  for  our  purpose  into  fixed  and 
changeable,  systemaized  and  unsystematized,  endogenous  and 
exogenous. 

A  fixed  delusion  is  one  which  seems  to  be  firmly  imbedded  in 
the  mind  and  is  continuously  adhered  to  by  the  patient,  while 


GENERAL  SYMPTOMATOLOGY.  65 

changeable  delusions  are  constantly  changing  and  giving  place 
one  to  another. 

An  unsystematized  delusion  does  not  enter  into  organic  com- 
binations with  the  other  facts  of  consciousness,  but  stands  apart 
and  seems  not  to  have  been  assimilated.  While  it  may  be  fixed, 
it  exercises  no  special  control  over  the  patient's  conduct ;  he  seems 
to  rest  with  its  statement  alone  unable  to  substantiate  his  position 
by  cogent  argument  or  example.  A  patient  who  believes  that  all 
the  bones  of  his  body  are  broken,  but  nevertheless  goes  about  his 
affairs  as  usual,  has  an  unsystematized  delusion. 

A  systematized  delusion,  on  the  other  hand,  is  not  only  assimi- 
lated and  associated  with  the  other  facts  of  conscious  experience 
but  forms  a  motive  power  for  conduct.  It  is  supported  by  rea- 
sons, by  arguments,  and  by  appeals  to  experience,  it  is  acted  upon 
as  if  it  were  an  actual  fact,  and  finally  it  may  so  reach  out  its 
influence  by  association  with  all  the  conscious  experiences  of  the 
individual  that  the  whole  life  of  the  patient  is  centered  about  and 
becomes  secondary  to  it.  The  patient  with  a  systematized  delu- 
sion of  persecution  regulates  his  whole  life  in  order  to  avoid  his 
persecutors.  The  food  is  carefully  tasted  for  poison  and  perhaps 
discarded,  the  bed  he  sleeps  in  must  be  insulated  to  prevent  elec- 
tric currents  being  applied  to  him  while  he  sleeps,  the  key-hole  and 
all  cracks  stopped  up  so  that  noxious  vapors  cannot  be  injected 
through  them.  If  the  patient  is  asked  for  an  explanation  of  this 
conduct  he  is  ready  with  interminable  reasons  and  appeals  to 
experience  while  his  arguments  are  woven  together  with  much 
ingenuity  and  no  little  logic.     His  delusion  is  systematized. 

The  distinction  of  endogenous  and  exogenous  is  thought  by 
Friedmann*  to  be  of  greater  importance  than  the  distinction  of 
systematized  and  unsystematized. 

The  endogenous  delusion  is  characterized  by  clear  logic,  contact 
with  reality,  taking  its  origin  from  actual  occurrences,  and  the 
important  distinction  that  it  represnts  a  delusional  unfolding  and 
elaboration  of  the  normal  thought  processes  of  the  patient.  In 
other  words  there  has  been  no  marked  change  in  the  personality, 
the  individual  is  the  same  sort  of  person  as  he  was  before  the 
growth  of  the  delusion.     The  delusion  seems  to  be  an  abnormal 

*  Friedmann,  M. :  Studies  in  Paranoia,  Nerv.  and  Ment.  Dis.  Monograph 
Series,  No.  2. 


66  OUTLINES   OF   PSYCHIATRY. 

expresion  of  his  character  and  quite  characteristically  after  re- 
covery from  the  psychosis  the  patient  cannot  be  made  to  under- 
stand the  delusional  character  of  his  experiences — he  lacks  insight. 

The  exogenous  delusion  on  the  other  hand  is  engrafted,  as  it 
were,  upon  the  personality  and  exists  there  parasitically  forming 
no  part  of  it.  These  patients  if  they  recover,  cannot  possibly 
understand  how  they  could  have  entertained  such  ideas  as  their 
delusions. 

A  further  classification  of  delusions  is  based  upon  Wernicke's 
classification  of  concepts.  It  is  a  very  valuable  and  practical  one 
from  a  clinical  standpoint.  Wernicke  classifies  concepts  as  to 
whether  they  relate  to  the  outside  world,  including  other  persons ; 
whether  they  relate  to  the  individual's  own  personality,  or  whether 
they  relate  to  the  individual's  own  body  and  speaks  of  the  psy- 
choses which  involve  these  three  orders  of  concepts  respectively 
as  aUopsychoses,  autopsychoses,  or  somatopsychoses.  A  person 
with  a  delusion  of  persecution  would  be  suffering  from  a  disturb- 
ance of  his  allopsychic  consciousness ;  if  he  had  a  delusion  that 
he  had  committed  the  unpardonable  sin  his  autopsychic  conscious- 
ness would  be  involved,  and  finally  if  he  believed  his  intestines  to 
be  stopped  up,  the  disorder  would  be  in  his  somatopsychic  con- 
sciousness. It  is  quite  possible,  even  common,  to  have  combi- 
nations of  these  varieties,  and  indeed  all  of  them  in  the  same 
patient,  so  the  patient  might  be  said  to  be  suffering  from  an  allo- 
auto-somatopsy  chosis . 

Before  leaving  the  subject  of  delusions  it  is  well  to  devote  a  few 
words  to  a  popular  misconception  regarding  them.  If  the  psy- 
choses are  conditions  arising  as  a  result  of  mal-adjustment  between 
individual  and  environment,  we  see  how  absurd  some  of  the  views 
are  which  grew  out  of  the  conceptions  of  the  old  "  faculty  psy- 
chology," and  neglected  to  consider  the  mind  as  a  mechanism  of 
adjustment,  all  parts  of  which  were  interrelated  with  one  another. 
Perhaps  the  most  widely  held  of  the  erroneous  beliefs  about  the 
psychoses  which  continues  to  evidence  the  influence  of  the  old 
psychology  is  the  belief  in  a  monomania,  or,  as  it  is  sometimes 
referred  to,  a  partial  insanity.  The  belief,  in  other  words,  that  a 
person  may  be  insane  on  one  subject  and  sane  on  all  others.  It  is 
true  that  we  may  have  a  psychosis  developed  about  a  centralized 
event  and  fairly  well  circumscribed  in  its  relations  to  that  event 
but  it  is  only  by  taking  the  view  that  an  idea  is  a  thing  apart  with- 


GENERAL   SYMPTOMATOLOGY.  6/ 

out  organic  connection  with  the  personality  of  the  individual  that 
we  can  conceive  of  a  person  with  a  single  wrong,  delusional  idea, 
yet  perfectly  all  right  every  other  way  .The  formation  of  an 
idea  is  dependent  upon  too  many  processes  and  cannot  spring 
into  being  indepenedntly  of  them  and  if  it  is  itself  pathological  we 
must  look  to  the  mechanism  of  its  growth  for  its  explanation. 
Mercier^  puts  this  very  well  when  he  says : 

"  The  delusion  is  not  an  isolated  disorder.  It  is  merely  the 
superficial  indication  of  a  deep-seated  and  widespread  disorder. 
As  a  small  island  is  but  the  summit  of  an  immense  mountain 
rising  from  the  floor  of  the  sea,  the  portion  of  the  mountain  in 
sight  bearing  but  an  insignificant  ratio  to  the  mass  whose  summit 
it  is,  so  a  delusion  is  merely  the  conspicuous  part  of  a  mental 
disease,  extending,  it  may  be,  to  the  very  foundations  of  the 
mind,  but  the  greater  portion  of  which  is  not  apparent  without 
careful  sounding.  Precisely  how  far  this  disorder  extends,  be- 
yond the  region  of  mind  occupied  by  the  delusion,  it  is  never 
possible  to  say;  but  it  is  certain  that  the  delusion  itself  is  the 
least  part  of  the  disorder,  and,  for  this  reason,  no  deluded  person 
ought  ever  to  be  regarded  as  fully  responsible  for  any  act  that 
he  may  do.  The  connection  between  the  act  and  the  delusion  may 
be  wholly  undiscoverable,,  as  the  shallow  between  two  neighbor- 
ing islands  may  be  entirely  hidden  by  the  intervening  sea.  But 
nevertheless,  if  the  sea  stood  a  hundred  fathoms  lower,  the  two 
islands  would  be  two  mountain  peaks  connected  by  a  stretch  of 
low  country;  and,  if  the  hidden  springs  of  conduct  were  laid 
bare,  the  delusions  and  the  act  might  be  found  to  have  a  common 
basis/* 

The  delusion  is  a  compromise  formation,  it  is  the  result  of  the 
psychological  conflict  and  may  therefore  be  compared  to  scar 
tissue.  It  is  the  best  result  that  can  be  reached  under  the  cir- 
cumstances yet  nor  a  normal,  wholesome  one. 

Hyper-quantivalent  Ideas. — In  speaking  of  ideas  we  use  the 
term  quantivalence  to  indicate  the  relative  value  which  the  idea 
has  in  the  consciousness  of  the  patient.  Under  ordinary  circum- 
stances when  the  mind  is  functioning  healthily  the  quantivalence 
of  ideas  is  normal,  but  it  not  infrequently  happens  that  owing  to 
pathological  processes  or  abnormal  environment  that  certain  ideas 
attain  a  degree  of  importance  altogether  unwarranted.      Under 

'  Mercier,  Charles :  Criminal  Responsibility,     Oxford,  1905. 


68  OUTLINES   OF   PSYCHIATRY. 

such  circumstances  we  speak  of  the  ideas  as  being  hyper-quantiv- 
dent.  This  condition  is  characteristically  seen  in  morbid  suspi- 
cions, ideas  of  a  persecutory  character,  founded  upon  a  very 
slight  basis  of  fact,  as  in  litigants  or  soldiers  who  have  been 
rebuked,  and  similar  conditions  occurring  in  paranoid  states. 
These  conditions  may  arise  upon  a  comparatively  normal  basis  in 
persons  who  are  subjected  to  abnormal  environmental  conditions, 
particularly  conditions  which  require  living  in  comparative  soli- 
tude or  in  close  association  with  a  few  peoule  to  the  exclusion  of 
all  others.  These  outward  conditions  are  often  seen  in  prisons 
and  in  secluded  army  posts. 

In  order  that  the  brain  may  continue  functioning  in  a  normal 
manner  it  is  necessary,  among  other  things,  that  its  contact  with 
an  environment  of  which  other  minds  form  a  part  should  be  con- 
tinuous and  of  a  sufficiently  varied  character  to  keep  the  process 
of  idea  association  active  and  from  getting  into  grooves.  Under 
normal  circumstances  a  slighting  remark  made  to  an  individual 
is  perhaps  received  by  a  retort  in  the  same  vein  and  the  normal 
rush  of  ideas  which  an  active  life  necessitates  soon  drowns  out 
or  submerges  this  particular  idea,  so  that  it  has  not  the  oppor- 
tunity to  constantly  recur  to  the  discomfort  of  the  individual.  It 
assumes  its  proper  relation  to  the  idea  content  of  consciousness, 
the  outward  facts  of  which  it  is  the  inner  representation  are  seen 
entirely  in  their  proper  perspective.  There  has  been  no  distor- 
tion of  the  normal  quantivalence  of  the  idea.  Under  abnormal 
environmental  conditions,  in  which  the  patient  leads  a  desultory 
mental  life,  where  each  day  is  much  like  the  preceding  and  there 
is  little  variety  of  idea  association  necessitated  by  daily  duties, 
there  is  nothing  to  prevent  such  an  idea  from  recurring  repeatedly 
to  the  individual,  and  because  of  this  recurrence,  and  because  it 
occupies  so  frequently  the  inner  consciousness,  the  outward  events 
to  which  it  corresponds  are  seen  in  a  distorted  perspective.  The 
idea  has  assumed  a  position  in  consciousness  totally  unwarranted 
by  its  real  importance.     It  has  become  hyper-quantivalent. 

Under  such  conditions  the  soldier  who  has  been  reprimanded 
broods  over  his  digrace  until  what  was  in  reality  a  small  afifair 
has  grown  by  constant  nursing  into  a  matter  of  tremendous  im- 
portance :  the  veteran  who  has  been  denied  a  pension,  the  litigant 
who  has  lost  a  law  suit,  have  been  greatly  wronged  and  cry  aloud 
for  justice.     The  narrow-minded  malcontents  who  see  life  from 


GENERAL   SYMPTOMATOLOGY.  69 

a  distorted  and  intensely  personal  viewpoint  are  the  favorable 
subjects  for  the  development  of  hyper-quantivalent  ideas. 

Fixed  Ideas. — The  term  fixed  idea  is  usually  applied  to  these 
conditions  and  as  a  term  designates  them  very  well.  The  fixed 
idea  must  be  hyper-quantivalent.  If  a  distinction  were  to  be 
made  it  might  be  made  on  the  basis  of  the  content  of  the  idea. 
Thus  hyper-quantivalence  is  usually  spoken  of  when  the  idea  has 
its  origin  in  the  allopsychic  consciousness.  The  litigant  pursuing 
case  after  case  to  obtain  his  rights,  or  the  discharged  employe 
making  repeated  appeals  for  investigation  are  examples.  The 
term  fixed  idea,  on  the  other  hand,  is  used  more  often  for  condi- 
tions arising  in  the  somatopsychic  or  autopsychic  field  of  con- 
sciousness. Thus  the  rather  timid  young  man  who  feels  his  pulse 
and  discovers  that  it  is  too  rapid  and  perhaps  somewhat  irregular 
acquires  as  a  result  a  fixed  idea  that  he  has  organic  disease  of 
the  heart.  The  woman  whose  husband  has  recently  died  and  who 
is  harrassed  by  the  belief  that  he  might  have  lived  had  she  given 
him  a  certain  medicine  has  a  fixed  idea. 

In  both  of  these  conditions,  however,  the  patient  feels  the  idea 
to  be  the  outgrowth  or  reaction  of  his  normal  self  and  not  in  any 
way  abnormal  or  an  obtrusion  from  without  as  in  the  cases  to 
follow. 

Obsessions. — By  obsessions  we  mean  ideas,  emotions,  impulses, 
which  occupy  consciousness  persistently  and  irrespective  of  the 
desires  of  the  subject,  often  intruding  themselves  at  inopportune 
times  and  occupying  the  field  of  consciousness  to  the  exclusion 
of  other  ideas.  They  are  sometimes  spoken  of  as  besetments,  as 
they  come  unbidden  and  refuse  to  go  at  the  will  of  the  subject. 
They  exist  with  clear  consciousness  and  are  often  fully  compre- 
hended by  the  patient  at  their  true  value. 

In  the  mild  forms  they  are  quite  common  and  occur  not  infre- 
quently in  normal  persons,  usually  as  a  result  of  fatigue.  We  are 
all  familiar  with  the  phenomena  of  the  constant  recurrence  to  the 
mind  of  a  tune  that  was  heard  the  night  before  at  the  opera;  it 
invades  consciousness  to  the  extent  of  actually  interfering  with 
the  transactions  of  the  usual  business  of  the  day.  Then  there  is 
the  somewhat  more  aggravated  case  of  the  person  who  goes  to  bed 
but  is  worried  for  fear  he  may  not  have  turned  the  gas-cock  quite 
shut;  he  tries  to  banish  the  idea,  turns  over  to  go  to  sleep  but  it 
will  not  go  and  finally  in  sheer  desperation  he  gets  up,  and,  satis- 


JO  OUTLINES  OF  PSYCHIATRY. 

fying  himself  that  the  gas  is  actually  turned  off,  returns  to  bed 
and  goes  to  sleep. 

The  commonest  and  best  known  of  the  obsessions  are  the  so- 
called  phobias  or  fears.  These  fears  are  usually  very  specific, 
referring  to  some  special  class  of  objects  or  set  of  conditions  and 
receive  names  accordingly.  Thus  we  have  misophobia  (fear  of 
dirt)  ;  metallophobia  (fear  of  metal,  such  as  door  knobs,  money, 
etc.)  ;  agoraphobia  (fear  of  wide  or  open  spaces)  ;  claustrophobia 
(fear  of  narrow  or  closed  spaces)  ;  pyrophobia  (fear  of  fire)  ; 
and  so  on  indefinitely.  Patients  suffering  from  these  obsessions 
are  often  completely  dominated  by  them  under  conditions  that 
call  them  into  existence.  The  patient  with  agoraphobia  crosses 
the  street  in  fear  and  trembling,  or  perhaps  cannot  summon  suffi- 
cient courage  to  cross  it  at  all  unless  some  one  is  with  him,  while 
on  the  contrary  the  claustrophobiac  cannot  endure  a  small  or 
closed  room,  but  must  have  the  doors  open,  or  if  in  a  crowded  hall 
is  suddenly  seized  with  fear  and  forced  to  make  a  hasty  exit. 

Of  not  infrequent  occurrence  also  are  the  obsessions  of  doubt. 
These  doubts  may  arise  about  anything,  even  the  simplest  acts 
of  everyday  life.  A  patient  upon  retiring  may  be  seized  with  a 
doubt  as  to  whether  he  turned  the  gas  off  or  locked  the  door  in 
the  main  hall,  and  is  forced  to  get  up  and  go  and  see,  only  to  be 
seized  again  by  the  same  doubt  when  he  returns  to  bed ;  another, 
having  written  several  letters,  is  forced  to  open  all  of  them  to 
make  sure  that  the  right  ones  are  in  each  envelope.  Still  others 
have  doubts  about  religious  or  metaphysical  matters.  So  we  have 
doubters  who  question  the  problem  of  a  future  life  or  the  exist- 
ence of  things  as  they  appear  to  the  senses,  etc. 

If  the  actions  which  the  obsessions  tend  to  initiate  are  resisted 
the  tendency  becomes  more  and  more  imperative  until  yielding  is 
forced  and  finally  these  patients,  although  fully  understanding 
their  condition  and  the  abnormality  of  their  ideas,  may  pass  their 
lives  in  a  continual  round  of  actions  made  necessary  by  their 
obsessions. 

Because  of  this  element  in  the  obsessed  state  that  impels  to 
action  these  conditions  are  often  spoken  of  as  imperative  ideas  or 
imperative  concepts. 

Autochthonous  Ideas. — These  ideas  come  into  the  patient's 
mind  like  foreign  bodies,  as  it  were,  apparently  not  as  a  result  of 
the  usual  methods  of  association.    The  patient  feels  that  he  has 


GENERAL   SYMPTOMATOLOGY.  /I 

Strange  thoughts,  thoughts  that  are  not  his  thoughts  and  usually 
interprets  their  occurrence  as  being  due  to  outside,  usually  malevo- 
lent, influences.  The  thoughts  are  forced  on  him  by  hypnotism, 
thought  transference,  by  his  enemies.  Bad  thoughts  are  thus 
placed  in  his  mind  and  often  he  is  forced  to  act  as  a  result  ot 
them  although  he  does  not  want  to  and  proclaims  that  it  is  all 
against  his  will. 

Disorders  of  the  Train  of  Thought. 

Flight  of  Ideas. — In  the  normal  process  of  thinking  our 
thoughts  are  directed  consistently  to  a  well-defined  end — the  goal 
idea — and  all  other  ideas  fall  into  a  subordinate  position  until  this 
is  attained.  The  course  of  the  train  of  thoughts  is  held  true  by  a 
guiding  idea'  (Obervorstellung). 

In  flight  of  ideas  the  patient  either  has  no  guiding  idea  or  else  at 
once  loses  it  so  that  there  is  no  consistent  effort  directed  towards 
attaining  the  goal  idea,  and  the  thought  therefore  wanders  here 
and  there  under  the  influence  of  chance  associations.  As  a  result 
the  train  of  thought  instead  of  progressing  changes  direction  fre- 
quently, returns  upon  itself,  and  never  reaches  any  logical  end. 
The  various  ideas  are  not,  however,  incoherent — they  do  not  fail 
to  be  connected  one  with  another,  although  it  may  be  quite  impos- 
sible at  times  to  see  just  what  that  connection  is.  If  the  asso- 
ciations are  external,  that  is,  originate  in  the  surroundings,  it  is 
usually  quite  possible  to  place  them;  when,  however,  they  are 
internal,  that  is,  originate  in  the  patient's  mind,  it  may  be  quite 
impossible  to  conceive  what  they  may  be.  An  example  will  illus- 
trate these  various  conditions: 

"  Do  you  know  I  was  kidnapped  to  be  sent  here  twice.  I  saw  a  mock 
funeral  of  me  before  I  left  home.  This  was  done  because  I  am  a  great 
inventor.  The  pope  of  Rome  is  the  greatest  human  being  in  the  universe. 
He  is  the  head  of  the  Catholic  Church.  My  head  (association  of  the 
word  head  in  two  different  meanings)  is  good  and  sound,  and  I  am  cer- 
tainly not  insane.  Do  you  hear  the  ticking  of  the  clock?  (External  asso- 
ciation.) It  says,  '  call  the  little  heifer,  the  heifer  is  sick.'  Did  you  ever 
see  the  gloves  veterinary  surgeons  use  when  they  doctor  sick  cows? 
(Internal  association.)  How  would  you  like  to  be  a  veterinary  surgeon? 
Say!  what  are  you  keeping  me  here  for  anyhow?  I  want  to  go  home. 
(Here  he  was  asked  how  he  slept  at  night.)  I  have  slept  excellently; 
that  is  because  I  am  of  such  a  strong  constitution.  The  constitution  of 
the  United   States    (association  as  above  with  the  word  head — probably 

«  Liepmann,  H. :  "Dber  Ideenflucht,  1904. 


72 


OUTLINES  OF   PSYCHIATRY. 


X     GOAL   IDE.A 


the  association  is  in  large  part  at  least  a  sound  or — as  it  is  called — a  clang 
association)  was  signed  by  Thomas  Jefferson.  He  was  just  a  man,  but 
he  was  not  the  inventor  I  am." 

While  there  are  many  places  in  the  example  where  the  con- 
necting link  is  missing — probably  because  it  was  an  association 
formed  entirely  within  the  patient's  mind — still  the  connection 
can  be  made  out  in  a  sufficient  number  of  instances  to  establish 
the  characteristics  of  the  train  of  thought.  One  of  the  principal 
characteristics  of  this  type  of  the  train  of  thought  is  its  great 
liability  to  change  of  direction  by  external  association,  as  for 
example,  the  ticking  of  the  clock  in  the  above  stenogram.  This 
quality  is  known  as  distractibility.  Any  sensory  impression  is 
liable  to  be  the  starting  point  of  idea-association,  so  that  these 
patients'  train  of  thought  may  be  turned  at  will,  almost,  by  such 
devices  as  shaking  a  bunch  of  keys  before  them,  saying  some  word 
loudly,  showing  them  a  newspaper,  or  in  other  words,  momentarily 

distracting  their  attention. 

This  condition  of  flight  of  ideas 
outwardly  appears  to  be  an  ex- 
pression of  an  increased  rapidity  of 
the  flow  of  idea-association.  How- 
ever, this  is  not  so,  as  an  example 
will  illustrate.  The  low  C  tuning- 
fork  used  in  testing  hearing  vi- 
brates 128  times  per  second.  If 
the  amplitude  of  vibration  which, 
although  it  is  readily  appreciable, 
is  only  a  small  fraction  of  an  inch, 
be  multiplied  by  128  the  resulting 
distance  would  be  but  a  few  inches 
at  most.  Let  the  fork  be  moved 
this  distance  in  one  second's  time 
and  the  motion  will  be  seen  to  be 
not  fast  by  any  means  but  slow. 
So  in  flight  of  ideas,  if  the  rapidity 
of  movement  in  a  given  direction 
by  idea-association  be  tested,  the 
release  of  ideas  will  be  found  to  be 
slow.  Like  the  tuning-fork,  how- 
ever, there  occurs  a  rapid  change  of  direction. 


INITIAL    IDEA 

Fig.  4.    Flight  of  ideas. 


GENERAL   SYMPTOMATOLOGY. 


73 


Tests  of  reaction  time  in  this  condition  show  that  it  is  abnor- 
mally slow  and  this  can  be  readily  elicited  by  giving  the  patient  a 
word  such  as  cat,  fur,  glass,  or  similar  simple  word,  and  asking 
him  to  write  down  as  rapidly  as  he  can  either  all  words  he  can 
think  of  rhyming  with  the  key-word  or  all  words  that  come  to  his 
mind  in  association  with  it.  The  slowness  with  which  these  tests 
are  executed  and  the  meagerness  of  the  result  will  be  in  marked 
contrast  to  the  apparent  wealth  of  ideas  and  facility  of  their  asso- 
ciation and  release. 

Circumstantiality. — Circumstantiality,  although  sometimes  su- 
perficially resembling  flight  of  ideas,  is  quite  different  from  it  in 
its  completely  developed  form.  Although  there  is  a  frequent 
change  of  direction  of  the  train  of  thought  the  goal  idea  is  main- 
tained and  ultimately  reached,  and  although  there  are  numerous 
digressions  as  each  circumstance  in  the  narrative  is  elaborated  and 
explained  the  original  pathway  is  returned  to  and  the  general 
direction  maintained.  Thus  a  patient  in  telling  about  a  cane  in 
her  possession  upon  which  a  ribbon  is  tied  for  ornament  must  tell 
how  she  came  to  have  the  idea  of  decorating  the  cane,  who  else 
in  the  neighborhood  had  such  a  cane  decorated,  what  they  had 
said  to  her  and  she  to  them  about  it,  how  she  had  taken  the  ribbon 
off  and  now  had  put  it  in  two  boxes  in  the  house,  how  the  ribbons 
had  become  faded,  where  she  got  the  boxes,  who  gave  them  to 
her,  and  what  their  color  was.  All  these  details  must  be  entered 
into  before  she  can  proceed  with  the  thread  of  her  narrative. 

This  condition  is  often  found  in  a  moderately  developed  form 
and  has  no  special  significance  other  than  showing  a  lack 
of  appreciation  of  the  relative  values  of  ideas.  In  the  senile, 
where  there  is  some  mental  impairment,  the  goal  idea  may  be  quite 
lost  sight  of  in  the  mass  of  detail  and  the  resemblance  to  fl'ght  is 
then  much  more  marked,  still  there  is  a  more  marked  tendency  to 
maintain  the  general  direction  of  the  train  of  thought. 

Retardation. — Retardation,  difficulty  of  thinking,  as  it  is  often 
called  to  distinguish  it  from  psychomotor  retardation,  shortly 
to  be  described,  is  a  decided  slowness  in  the  elaboration  of  ideas, 
the  patient's  stock  of  ideas  do  not  seem  to  be  available  or  access- 
ible, ideas  come  slowly  to  the  mind,  there  is  a  great  difficulty  in 
forming  judgments,  in  coming  to  conclusions,  in  reaching  deci- 
sions which  is  felt  by  the  patient  as  an  inadequacy  in  dealing  with 
6 


74  OUTLINES   OF   PSYCHIATRY. 

mental  problems.  This  condition  is  expressed  by  the  patient  in 
great  slowness  of  speech,  a  long  interval  elapsing  before  an  an- 
swer is  given  to  a  question  or  something  done  as  requested  (initial 
retardation) ,  and  when  the  question  is  answered  or  the  act  done 
it  is  done  very  slowly  and  deliberately  (executive  retardation). 

If  such  a  patient  be  asked  to  count  from  one  to  twenty,  begin- 
ning at  a  given  signal  and  counting  as  fast  as  possible,  it  may  be 
several  seconds  before  he  starts,  and  while  a  normal  person  should 
do  this  in  two  or  three  seconds,  he  may  take  often  twenty,  thirty, 
or  even  never  finish  at  all. 

Paralysis  of  Thought. — A  complete  absence  of  all  internally 
initiated  conscious  processes.  Impressions  from  without  are  not 
assimilated,  form  no  associations,  leave  no  traces.  Mental  life  is 
in  abeyance  or  abolished. 

Disorders  of  (Volition)  Action. 

Decreased  Psychomotor  Activity. — This  symptom  corresponds 
in  the  motor  sphere  to  difficulty  of  thinking  in  the  psychic  sphere. 
Whereas  in  difficulty  of  thinking  we  might  say  that  there  was  a 
slowness  in  the  Hberation  of  ideas  in  psychomotor  retardation,  we 
can  say  there  is  a  slowness  in  the  liberation  of  voluntary  motor 
responses.  The  patient's  movements  are  slow  and  deliberate,  and 
we  find  here  the  same  distinction  of  initial  and  executive  retarda- 
tion.   This  is  a  prominent  symptom  of  depressive  melancholia. 

Increased  Psychomotor  Activity. — This  is  just  the  opposite 
of  the  above  condition,  and  is  due  to  an  abnormally  facile  release 
of  voluntary  motor  responses.  It  manifests  itself  in  great  rest- 
lessness, constant  activity,  even  to  the  point  of  violence  and  de- 
structiveness,  and,  like  flight  of  ideas,  the  various  acts  are  not 
consistently  directed  to  a  definite  goal  but  to  this  and  that  end 
under  the  influence  of  chance  associations.  This  is  a  prominent 
symptom  of  manic  excitement. 

Impulsion. — Impulsions  or  impulses  are  tendencies  to  act  which 
are  more  or  less  uncontrollable,  often  absolutely  so.  The  act  may 
be  of  any  kind  and  in  this  class  belong  the  so-called  manias,  such 
as  kleptomania  (a  morbid  impulse  to  steal),  pyromania  (a  morbid 
impulse  to  set  things  on  fire),  dipsomania  (an  impulse  to  drink), 
etc.  These  impulses  appear  without  cause,  the  patient  is  restless 
until  they  are  carried  out,  and  their  accomplishment  is  accom- 
panied by  a  feeling  of  relief. 


GENERAL   SYMPTOMATOLOGY.  75 

Compulsion. — Closely  allied  to  the  impulses  are  the  so-called 
compulsions.  The  compulsions,  like  the  obsessions,  already  de- 
scribed, are  felt  by  the  patient  to  be  pathological,  to  be  forced 
upon  him,  as  it  were.  The  impulse  of  the  dipsomaniac,  like  the 
fixed  idea,  is  conceived  by  the  patient  as  originating  within  and 
being  a  part  of  him,  a  natural  development  of  his  character,  per- 
haps, while  the  compulsion  is  often  directed  to  the  doing  of  some 
act  distinctly  abhorrent  to  the  patient,  such  for  instance,  as  mur- 
der, and  he  may  take  elaborate  precautions  to  protect  others  or 
even  have  himself  locked  up  to  insure  against  its  possibility. 

If  these  compulsions  are  resisted  or  interfered  with  they  give 
rise  to  certain  symptoms  which  in  marked  cases  constitute  a  veri- 
table crisis.  The  patient  feels  weak,  trembles,  becomes  dizzy, 
perspires,  and  finally  yields  to  find  that  at  once  all  these  symp- 
toms disappear. 

Stereotypy. — In  stereotypy  the  voluntary  impulse  once  set  in 
motion  tends  to  continue  or  repeat  itself  in  the  same  way  indefi- 
nitely, thus  we  have  three  forms  of  stereotypy,  viz.,  stereotypy 
of  attitude,  of  movement,  and  of  speech. 

In  stereotypy  of  attitude  the  patient  tends  to  maintain  a  par- 
ticular, usually  peculiar,  position,  such  as  standing  in  the  comer, 
one  arm  raised,  lying  on  the  bed  with  the  head  hanging  over  the 
side.  The  muscles  are  usually  tense  and  the  patient  resists  at- 
tempts to  alter  his  position. 

Stereotypy  of  movement  manifests  itself  in  the  continuous 
repetition  of  some  movement,  usually  meaningless,  such  as  sway- 
ing back  and  forth,  nodding,  wrinkling  the  forehead  or  the  like. 
When  the  word  stereotypy  is  used  without  qualification  this 
variety  is  referred  to.  When  these  peculiarities  are  constant  and 
characteristic  of  the  patient,  particularly  if  they  occur  in  connec- 
tion with  his  ordinary  conduct,  such  as  peculiarities  of  walking, 
eating  at  table,  or  in  speaking,  they  are  usually  spoken  of  as 
mannerisms. 

Stereotypy  of  speech  shows  itself  in  the  constant  repetition  of 
the  same,  usually  senseless,  phrases,  and  is  more  commonly  known 
as  verbigeration. 

The  persistence  of  a  motor  impulse,  whether  in  action,  speech 
or  writing,  and  commonly  expressing  itself  by  the  iteration  and 
reiteration  of  the  same  word  or  phrase,  generally  in  an  attempt 


y^  OUTLINES  OF   PSYCHIATRY. 

to  answer  a  question,  is  called  perseveration.  It  may  not  be  at  all 
senseless,  but  simply  show  the  tendency  of  a  motor  impulse  once 
generated  to  hold  the  field,  as  in  the  following  letter  written  to 
me  by  a  young  epileptic. 

"  May  21  st,  1907.  Supt.  Wm.  A.  White  I  would  like  to  have  a  talk  with 
you  about  matters  my  papa  advise  me  to  do.  How  can  I  get  to  see  you? 
will  you  come  to  see  me  or  can  I  come  to  see  you?  I  would  like  very 
much  to  see  you  Supt.  Wm.  A.  White  I  am  well  but  I  want  to  see  you  so 
I  can  have  a  talk  with  you  about  matters  that  my  papa  advise  me  to  do  I 
am  feeling  all  right  now  than  I  did  some  years  ago  but  I  would  like  to 
see  you  and  have  a  talk  with  you  about  matters  that  my  Papa  advise  me 
to  do  and  I  would  be  very  thankful  to  you  Supt.  Wm.  A.  White  if  I  could 
get  to  see  you  please  do  it  for  me  so  I  can  have  a  Talk  with  you  about 
matters  my  papa  advised  me  to  do." 

Negativism.'^ — Negativism  is  a  peculiar  condition  which  is 
manifested  by  the  patient  not  doing  what  is  expected  of  him 
(passive  negativism)  or  doing  the  opposite  of  what  he  is  re- 
quested to  do  (active  negativism).  Every  attempt  to  get  the 
patient  to  do  anything  results  in  failure  with  perhaps  certain  signs 
of  irritation  or  the  release  of  a  motor  impulse  the  exact  opposite 
of  that  required  for  the  performance  of  the  act. 

Patients  exhibiting  this  symptom  not  only  do  the  opposite  of 
what  is  requested  of  them  but  exhibit  negativistic  tendencies 
toward  the  promptings  of  normal  desires.  They  do  not  yield  to 
the  inclination  to  empty  the  bladder  or  rectum,  so  that  these 
organs  often  become  overloaded  with  disastrous  results.  They 
often  also  permit  saliva  to  accumulate  in  large  quantities  in  the 
mouth,  even  until  it  has  undergone  putrefactive  changes. 

Suggestibility. — Suggestibility  may  be  said  to  be  the  exact  op- 
posite of  negativism.  The  patient's  reactions  are  determined  by 
impressions  or  suggestions  derived  from  others.  It  is  manifested 
in  various  ways.  In  extreme  cases  the  patient  resembles  a  lay 
figure;  the  limbs  can  be  placed  in  any  position  and  are  there  re- 
tained indefinitely.  This  condition  is  designated  as  catalepsy,  or 
flcxibilitas  cerca  (waxy  flexibility).  Often  suggestibility  is  mani- 
fested by  the  patient  repeating  words  or  phrases  said  in  his  pres- 
ence— echolalia — or  actions  done  before  him,  such  as  taking  out 
the   watch,   putting  the  hands  to  the    face — echopraxia.     This 

'Bleuler:  The  Theory  of  Schizophrenic  Negativism  (trans,  by  White), 
Nerv.  and  Ment.  Dis.  Monograph  rSeries,  No.  11. 


GENERAL   SYMPTOMATOLOGY.  yy 

method  of  reaction  in  which  personal  initiative  seems  to  be  abso- 
lutely in  abeyance  is  often  spoken  of  as  automatic — the  symptom 
is  known  as  automatism.  When  the  automatic  responses  are  to 
commands  then  the  term  command  automatism  is  used. 

Stupor.  Stupor  is  a  condition  in  which  there  is  usually  a  pro- 
found disturbance  of  consciousness,  but  the  feature  which  gives 
it  its  distinctive  outward  character  is  psychomotor  inhibition — 
voluntary  motion  is  to  a  greater  or  less  extent  in  abeyance.  The 
mental  state  in  the  different  varieties  of  stupor  differs  greatly 
from  profound  clouding  of  consciousness  to  almost  clear  con- 
sciousness, as  in  the  catatonic  stupor  of  dementia  precox.  To 
this  latter  condition,  in  which  the  patient,  although  quite  immo- 
bile, is  still  fully  alive  to  what  is  going  on  about  him,  the  term 
pseudo-stupor  has  been  given. 

Disorders  of  (Emotion)  Feeling. 

Exaltation. — Exaltation  is  a  condition  of  morbid  emotional  ela- 
tion, a  feeling  of  happiness  and  well-being  not  warranted  by  the 
condition  of  the  patient  or  his  surroundings.  It  is  one  of  the 
most  prominent  symptoms  of  mania,  and  is  here  combined  with 
increased  psychomotor  activity.  With  exaltation  is  often  asso- 
ciated a  marked  degree  of  irritability  with  sometimes  outbursts 
of  angry  states. 

Depression. — Depression  is  the  opposite  of  exaltation.  It  is  a 
morbid  feeling  of  unhappiness  not  warranted  by  the  condition  of 
the  patient  or  his  surroundings.  It  is  one  of  the  most  prominent 
symptoms  of  melancholia,  and  in  that  variety  known  as  affective 
or  involution  melancholia  often  gives  rise  to  a  state  of  anxiety 
with  marked  precordial  distress,  difficulty  of  breathing,  and  some 
motor  agitation. 

Emotional  Deterioration. — A  condition  of  poverty  of  the  emo- 
tions manifesting  itself  by  indifference  and  occurring  in  conditions 
of  mental  deterioration,  particularly  seen  in  dementia  precox, 
paresis  and  senility. 

Morbid  Anger. — This  symptom,  except  as  due  to  transient 
conditions  of  irratibility,  as  in  mania,  is  seen  most  often  in  the 
defective.  It  is  often  a  marked  feature  in  idiots  and  imbeciles, 
constituting  them  very  dangerous  patients,  but  is  also  seen  among 
the  higher  defectives,  the  morally  deficient,  and  is  here  often  com- 
bined with  great  cruelty. 


7$  outlines  of  psychiatry. 

Disorders  of  Memory. 

Amnesia. — Amnesia  is  loss  of  memory.  The  loss  may  be 
circumscribed — only  for  certain  things  or  extending  over  a  very 
definite  space  of  time — or  it  may  be  more  general.  Loss  of 
memory  extending  over  definite  periods  of  time  is  usually  the 
result  of  illness  or  injury.  In  such  cases  the  amnesia  usually  has 
a  fairly  definite  beginning  with  the  delirium  of  the  illness  or  the 
occurrence  of  the  injury  and  usually  also  a  fairly  definite  ending. 
It  is  known  as  retrograde  amnesia.  If,  on  the  contrary,  the  am- 
nesia is  continuous,  the  patient  seems  to  be  no  longer  able  to  store 
up  memories,  as  is  so  typically  seen  in  the  senile,  the  amnesia  is 
anterograde  amnesia. 

Hypermnesia. — An  exaggerated  degree  of  retentiveness,  often 
seen  in  the  remarkable  memory  for  details  in  some  cases  of 
chronic  delusional  psychoses,  who  seem  to  remember  every  detail 
in  their  lives  as  bearing  on  their  delusional  system. 

Paramnesia. — ^This  is  a  disorder  of  memory  in  which  events 
are  remembered  which  never  happened.  An  example  of  this  was 
afforded  by  a  patient  who  stopped  me  while  I  was  going  through 
the  ward  and  told  me  that,  while  she  was  dining  in  another  ward, 
I  had  entered  the  dining-room  and  informed  her  that  any  time 
her  satchel  was  ready  she  could  go.  As  a  matter  of  fact,  I  had 
not  even  seen  the  patient  upon  the  occasion  she  referred  to. 
When  these  false  memories  are  projected  into  the  past  and  asso- 
ciated with  delusions,  often  of  an  explanatory  nature,  as  occurs 
in  paranoia,  the  symptom  is  known  as  retrospective  falsification 
of  memory. 

Disorders  of  Attention. 

Aprosexia. — This  is  the  condition  of  inability  to  fix  the  atten- 
tion for  any  length  of  time  in  one  direction  and  is  seen  typically 
in  mania.  Here  the  attention  wanders  rapidly  from  one  thing 
to  another  and  as  a  result  perception  is  inadequate.  The  different 
elements  of  the  environment  are  not  attended  to  sufficiently  to 
insure  their  correct  perception.  This  insufficiency  of  perception 
gives  rise  to  the  maniac's  defects  of  orientation  most  frequently 
seen  with  respect  to  persons,  some  slight  resemblance  being  hit 
upon  and  the  person  mistaken  for  someone  else,  a  former  ac- 
quaintance or  associate. 

Enfeeblement  of  the  power  of  voluntary  attention  is  one  of  the 


GENERAL   SYMPTOMATOLOGY.  79 

most  characteristic  of  the  signs  of  deterioration  and  is  a  promi- 
nent symptom  in  the  various  deterioration  psychoses,  for  exam- 
ple, in  dementia  precox. 

Hyperprosexia. — In  this  condition  the  attention  of  the  patient 
is  completely  absorbed  by  some  thoughts,  usually  by  his  delusions. 
This  complete  absorption  also  gives  rise  to  disorders  of  percep- 
tion, as  the  environment  is  not  attended  to  and  often  not  perceived 
at  all.  The  condition  may  give  rise  to  actual  delusions.  A  young 
woman,  who  was  suffering  from  the  most  profound  melancholia 
with  painful  delusions,  was  so  absorbed  in  these  that  she  did  not 
perceive  the  tray  of  food  that  was  brought  to  her  and  subse- 
quently when  it  was  brought  to  her  notice  thought  some  mys- 
terious power  must  be  responsible  for  its  presence. 

Disorders  of  Personality. 

To  understand  these  disorders,  we  must  understand  what  con- 
stitutes personality.  The  individual,  besides  receiving  certain 
information  from  the  environment  and  forming  certain  ideas,  has 
beyond  this  a  consciousness  of  self,  a  feeling  that  all  his  per- 
ceptions and  ideas  are  experiences  of  a  single  self,  a  self  that 
maintains  its  own  idividual  identity  throughout,  and  which  the 
individual  calls  "  I."  This  problem  of  self-consciousness,  al- 
though the  riddle  of  psychology,  presents  certain  features  useful 
in  elucidating  the  problem  in  hand. 

Our  consciousness,  as  we  know  it,  is  subject  to  many  interrup- 
tions, many  lapses,  so  that  in  an  ordinary  lifetime  hiatuses  appear 
in  its  course,  yet  the  notion  of  personal  identity  is  not  thereby 
destroyed.  For  example,  every  profound  sleep  destroys  the  con- 
tinuity of  consciousness.  We  may  conceive,  however,  that  under- 
lying all  these  manifestations,  such  as  disappear  from  view  in 
the  profundity  of  sleep,  there  are  certain  permanent  features 
which  form  the  foundation,  the  continuum  of  consciousness  upon 
which  the  transitory  features  as  we  see  them  are  erected  as 
epiphenomena.  The  most  important  element  in  this  fundamental 
continuum  is  the  ccenesthesis — made  up  of  what  we  must  con- 
ceive as  a  continuous  flow  of  sensations  from  all  the  organs  of  the 
body  to  the  mind.  This  flow  of  sensations  is  constant  through- 
out life,  and  in  the  absence  of  disease  varies  little  either  as  to 
quality  or  intensity.  It  is  the  continuous,  ever  present  element  of 
our  consciousness.    The  other  elements,  of  which  we  have  directly 


80  OUTLINES   OF   PSYCHIATRY. 

a  better  knowledge,  made  up  for  the  most  part  of  perceptions  of 
the  outer  world  of  reality,  vary  much  more  in  correspondence  to 
many  factors,  particularly  as  to  the  nature  of  the  environment, 
and  the  characteristics  of  the  perceiving  mind  as  the  result  of  past 
experiences.  It  is  these  two  elements  of  consciousness  which 
make  up  the  personality. 

Transformation  of  the  Personality. — This  phenomenon  is  seen 
in  the  paranoid  conditions  typically,  the  gradual  growth  of  a 
delusional  system  accompanied  and  probably  to  some  extent  de- 
pendent upon  disorders  in  the  realm  of  the  organic  sensations. 
The  paranoiac,  with  his  profound  disturbance  of  allo-psychic  con- 
sciousness, sees  the  outer  world  of  reality  twisted,  deformed,  as 
though  he  were  reviewing  it  through  an  astigmatic  medium.  All 
the  facts  of  his  life,  his  knowledge  of  the  world  are  distorted  to 
conform  to  the  deformity  of  the  medium  through  which  he  views 
them.  Not  only  are  these  elements  of  his  personality  seriously 
disordered,  but  its  very  foundation — the  ccenesthesis — is  also 
seriously  disturbed,  as  seen  particularly  in  the  first  stage  of  the 
disease.  All  of  the  elements  that  go  to  make  up  the  patient's 
personality  being  so  completely  disordered,  the  expressions  of 
that  personality  are  similarly  disordered  and  we  have  the  picture 
of  the  third  stage,  the  final  result  of  the  disease  process  in  its 
natural  unfolding — transformation  of  the  personality. 

Depersonalization. — A  lesser  degree  of  the  same  sort  of 
process  results  in  a  disorganization,  a  breaking  up  of  the  per- 
sonality. This  is  seen  in  many  conditions  and  is  associated  with 
a  feeling  of  unreality,  and  occurs  as  a  part  of  the  delirium  of 
negation.  The  patients  proclaim  that  they  are  changed,  they  are 
not  themselves.  One  of  my  patients  would  look  in  the  glass  and 
stare  in  wonder  at  her  reflection,  saying  her  eyes  were  not  hers, 
they  were  cat's  eyes.  Another  patient  affirmed  she  had  no  head, 
no  arms,  no  body,  no  mind,  nothing.  The  feeling  of  personal 
identity  in  these  cases  has  become  disrupted,  the  personality  dis- 
organized. 

Multiple  Personality. — In  this  condition  the  patient  passes 
through  stages  in  each  of  which  the  personality  is  different.  The 
usual  cases  are  those  in  which  a  secondary  personality  grows 
up  in  the  individual  and  at  times  overwhelms  the  normal  per- 
sonality and  occupies  the  stage  to  its  exclusion.     These  are  the 


GENERAL  SYMPTOMATOLOGY.  8  I 

cases  of  so-called  double-consciousness.  The  two,  or  sometimes 
more  personalities  are  usually  separated  from  each  other  by  com- 
plete amnesia,  so  that  one  does  not  know  of  the  existence  of  the 
other, 

Ganser's  Symptom. 

Ganser's  symptoms  or,  as  it  has  been  called,  the  symptoms  of 
approximate  answers^  (Danebenreden)  is  sufficiently  frequent  to 
deserve  notice.  Its  designation  as  the  symptom  of  approximate 
answers  serves  very  well  to  describe  it.  An  illustration  will  make 
it  quite  clear.  A  patient  gives  the  following  results  in  calculation 
tests:  7X6=41,  4X8  =  36,  6X7  =  43- 

Another  patient  gives  the  following  replies  to  questions: 

Ques.  What  year  is  this  (1907)  ?    Ans.  1907,  I  think. 

Ques.  What  is  the  month  (Feb.)  ?    Ans.  It  might  be  January. 

Ques.  What  is  the  day  of  the  week  (Wednesday)  ?  Ans. 
Tuesday. 

This  patient  gave  the  following  results  to  calculation  tests : 
17  +  16  =  21,  9+  7=16,  3  X  7  =  20 — when  told  he  was  wrong 
said  22,  19 — 13  =  8,  ain't  it? 

This  symptom  has  been  supposed  to  be  rather  characteristic  of 
hysteria  but  it  has  been  found  in  many  conditions.  My  own  ex- 
perience leads  me  to  believe  that  it  is  rather  characteristic  of 
states  of  psychopathic  inferiority. 

The  "Complex."' 

The  mind  cannot  be  conceived  of  as  consisting  of  or  containing 
ideas  which  are  deposited  here  and  there,  helter  skelter,  without 
order,  as  the  scraps  of  paper  that  are  thrown  carelessly  into  the 
waste  basket.  Quite  the  contrary.  Ideas  are  grouped  about  cen- 
tral experiences,  constellated  as  we  say,  built  into  coherent  and 
harmonious  structures  not  unlike  the  way  in  which  bricks  and 
stones  are  brought  together  to  form  buildings  and  these  buildings 
are  again  grouped  to  form  the  larger  whole — ^the  city.  The  sig- 
nificant fact  in  this  connection  is  that  the  cement  that  holds  the 
bricks  and  stones  together,  the  binding  substance,  is  feeling. 

8  Ruggles,  A.  H. :  Observations  on  Ganser's  Symptom,  Am.  Jour,  In- 
sanity, Oct.,  1905. 
•'White:  Mental  Mechanisms,  No.  8  of  this  Series. 


82  OUTLINES   OF   PSYCHIATRY. 

This  orderly  arrangement  of  ideas  upon  a  background  of  feeling 
which  serves  to  unite  them  is  what  gives  character,  individuality 
to  the  personality.  The  creating  of  the  proper  feeling-tone  about 
things  and  events  is  one  of  the  main  functions  of  education. 

Now  it  so'  happens  that  in  certain  types  of  individuals  a  con- 
stellation of  ideas,  grouped  about  a  central  event  that  conditions 
a  highly  painful  emotional  state,  is  crowded  out  of  clear  conscious- 
ness— repressed — into  the  region  of  the  unconscious  and  so  tends 
to  lead  an  existence  which  is  relatively  independent  and  in  so 
doing  gives  origin  to  various  symptoms.  Such  a  constellation  has 
been  known  for  many  years,  especially  in  France  and  in  this 
country  as  a  "  dissociated  state  "  but  more  lately  as  a  "  complex." 

The  complex,  crowded  out  of  relation  with  the  personal  con- 
sciousness, seeks  for  expression  and  because  it  is  not  synthetized 
with  the  rest  of  consciousness,  because  the  individual  is  not  aware 
of  its  existence,  its  expression  cannot  be  controlled  and  guided 
into  the  usual  channels  and  so  creates  the  symptoms  of  the  psy- 
choneurosis  or  psychosis. 

The  extreme  difficulty  in  locating  and  uncovering  the  complex 
is  due  to  the  symbolic  forms  in  which  it  usually  manifests  itself. 
The  painful  memories  of  disagreeable  experiences,  unethical,  un- 
conventional, and  otherwise  impossible  and  hateful  wishes  while 
crowded  out  of  mind  by  what  Freud  has  so  aptly  termed  the 
"  censor  of  consciousness  "  nevertheless  struggle  to  find  expres- 
sion. The  complex  cries  for  recognition,  the  censor  will  have 
none  of  it — the  fight  is  on,  the  conflict  wages,  until  finally  a  sort 
of  compromise  is  reached  by  permitting  the  complex  to  come  into 
clear  consciousness  but  only  on  pain  of  not  disclosing  its  true  self, 
under  the  cloak  of  a  complete  disguise. 

For  example  Freud's  case  of  Elisabeth.^"  She  was  engaged  in 
nursing  her  sick  father  who  afterwards  died.  One  evening,  spent 
away  from  home  at  the  solicitation  of  the  family,  she  met  a  young 
man  of  whom  she  was  very  fond  and  he  accompanied  her  back 
home.  On  the  walk  home  she  quite  gave  herself  up  to  the  happi- 
ness of  the  occasion  and  walked  along  oblivious  of  her  duties. 
On  reaching  home  she  found  her  father  much  worse  and  bitterly 
reproached  herself  for  forgetting  him  in  her  own  pleasure.     She 

10  Freud :  Selected  Papers  on  Hysteria  and  Other  Psychoneuroses,  Jour, 
of  Nerv.  and  Ment.  Dis.  Monograph  Series,  No.  4. 


GENERAL   SYMPTOMATOLOGY.  83 

immediately  repressed  this  disagreeable  thought  from  her  con- 
sciousness. Now  she  had,  each  morning,  to  change  the  dressings 
on  her  father's  swollen  leg.  To  do  this  she  took  his  leg  upon  her 
right  thigh.  The  suppressed  complex  seized  upon  the  feeling  of 
weight  and  pain  of  her  father's  leg  upon  her  thigh  as  a  handy  and 
efficient  means  of  expression  and  so  the  repressed  erotic  wish 
comes  into  consciousness  under  the  disguise  of  a  painful  area  of 
the  right  thigh  corresponding  in  extent  and  location  to  the  place 
upon  which  she  rested  her  father's  leg. 

This  is  the  sort  of  mechanism  that  accounts  for  many  unusual 
and  strange  experiences  that  otherwise  appear  to  be  without  rea- 
son. Unexplained  forgetting,  slips  of  the  tongue,  certain  mental 
attitudes,  moods,  and  even  the  dominant  traits  of  character  are 
due  to  the  activity  of  submerged  complexes  while  the  phenomena 
of  dreams  are  explained  in  the  same  way. 

Dreams. 

As  already  described  the  complex  often  expresses  itself  sym- 
bolically (symbolism) ,  often  by  the  transfer  of  an  emotion  from 
a  painful  event  to  a  less  painful  or  indifferent  event  (displace- 
ment), often,  as  in  hysteria,  by  the  conversion  of  the  conflict  into 
a  physical  symptom  (conversion). 

The  importance  of  dreams  is  due  to  the  fact  that  the  mech- 
anisms that  produce  them  are  the  same  as  the  mechanisms  of  the 
symptoms.  Both  express  themselves  by  symbols  in  order  to  dis- 
guise the  painful  tendencies  which  are  seeking  expression.  The 
object  of  displacement  is  the  same.  For  example,  a  person  who 
in  his  youth  learned  to  hate  someone  very  much  who  happened 
to  have  red  hair  later  dislikes  all  people  with  red  hair.  Red  hair 
thus  becomes  the  symbol  of  the  hated  person  and  also  the  hate  is 
projected  upon  the  hair  (displacement)  rather  than  the  person. 
So  the  individual  can  indulge  his  hate  without  having  the  dis- 
agreeable experience  of  having  to  recall  the  forgotten  experiences. 

Dormant  complexes  produce  many  of  the  symptoms  which  are 
seen  in  the  psychoses.  When  the  complex  has  to  find  expression 
through  the  medium  of  a  mind  seriously  disintegrated  by  deteri- 
oration processes  the  results  are  extremely  difficult  to  unravel. 
The  method  of  approach  at  present  most  in  vogue  is  by  associa- 
tion tests — psychoanalysis.     (See  Chapter  VI.) 


84  OUTLINES   OF   PSYCHIATRY. 

Dreams  for  Freud  are  sleep  conserving  in  their  function.  The 
suppressed  complexes  during  sleep  seize  upon  the  opportunity  to 
slip  out  from  their  enforced  retirement.  Should  they  succeed 
sleep  would  be  disturbed' — impossible.  The  censor,  therefore, 
compels  them  to  assume  strange  forms  so  that  they  may  not  be 
recognized  for  what  they  really  are  and  so  strike  terror  to  the 
heart  of  the  sleeper  and  cause  him  to  awaken.  If  for  any  reason 
the  censor  has  been  lulled  into  fancied  security,  rendered  dormant 
and  inactive  by  sleep,  and  the  appearance  of  the  undisguised  com- 
plexes in  clear  consciousness  seems  imminent  then  the  phenomena 
of  nightmare  result  and  to  prevent  the  dreaded  denouement  the 
sleeper  awakes  and  thus  arouses  the  censor  to  full  activity  and 
power  to  keep  them  down. 

The  study  of  dreams^^  has  become  of  great  importance  in  psy- 
choanalysis. Since  no  mental  state  can  be  fortuitous,  since  the 
content  of  consciousness  at  any  one  time  must  be  causally  de- 
pendent upon  what  has  preceded,  a  study  of  the  dream  must 
therefore  throw  light  upon  the  mental  makeup  of  the  dreamer. 
Dreams  have  been  shown  to  be  closely  related  to  delusions  and  to 
psychoneurotic  symptoms  and  their  analysis  is  very  important  for 
the  unravelling  of  those  symptoms. 

11  White:  Mechanisms  of  Character  Formation.  New  York,  The  Mac- 
millan  Co.     1916. 

Jones :  The  Relationship  Between  Dreams  and  Psychoneurotic  Symp- 
toms, Am.  Jour.  Insanity,  July,  191 1. 

Jelliffe:  Technique  of  Psychoanalysis,  No.  2(i  of  this  Series. 


PART  II 
CLINICAL. 


CHAPTER  VIII. 
Paranoia  and  Paranoid  States. 

Paranoia. 

Historical. — The  term  paranoia  was  used  by  the  ancient  Greeks 
to  designate  a  kind  of  thinking  that  was  "  beside  itself  " ;  it  might 
be  the  present  equivalent  of  a  mind  distraught,  or  distracted  with 
grief  or  agony.  It  disappeared  from  use  and  did  not  reappear  in 
psycharity  until  the  Middle  Ages  when  it  was  synonymous  with 
craziness  in  general.  Heinroth  in  the  early  part  of  the  nineteenth 
century  used  the  term  to  include  special  types  of  acute  confused 
thinking  (delirium),  a  trend  which  as  been  followed  by  certain 
psychiatrists  to  the  present  day — as  seen  notably  in  Ziehen.  An- 
other trend  has  been  to  apply  the  term  to  a  group  of  disturbances 
characterized  by  chronic  delusional  formation.^ 

Description  of  the  Psychosis. 

The  basis  upon  which  so-called  "true  paranoia"  has  been 
separated  from  other  conditions  is  the  absence  of  intellectual  im- 
pairment. When  a  paranoid  condition  was  associated  with 
marked  intellectual  impairment  the  diagnosis  has  usually  been 
dementia  precox.  Inasmuch  as  we  have  no  well  accepted  criteria 
for  determining  the  existence  of  dementia  this  distinction  is  now 
of  little  use.  The  woman  whose  case  I  have  quoted  elsewhere, 
who  expressed  the  idea  that  her  husband  was  untrue  to  her, 
did  not  thereby  show  any  signs  of  intellectual  impairment  or 
express  an  idea  which  inherently  showed  any  evidences  of  intel- 
lectual impairment.  When,  however,  she  adduced  as  proof  of 
this  statement  the  fact  that  when  she  looked  out  upon  the  street 
in  the  morning  following  a  snow  storm  of  the  night  before  she 
saw  numerous  foot-prints  of  a  woman  who  had  been  to  the  house 
during  the  night  to  meet  her  husband,  and  without  any  additional 

ijelliffe:  Study  of  Origin  of  Paranoia  Concept,  Jour,  of  Nerv.  and 
Ment.  Dis.,  1913. 

87 


S8  OUTLINES   OF  PSYCHIATRY. 

facts  presents  this  argument  in  support  of  her  previous  state- 
ment, there  is  some  justification  in  saying  that  her  judgment  in 
this  specific  instance  is  poor,  and  when  it  is  found  that  all  of  her 
arguments  in  support  of  her  idea  are  of  a  similarly  flimsy  and 
unwarranted  character,  there  is  warrant  in  saying  that  her  judg- 
ment is  impaired,  which  is  tantamount  to  saying  that  her  intellect 
is  impaired.  Although  this  patient  talked  reasonably  about  most 
things,  was  acute  to  perceive,  and  under  ordinary  circumstances 
showed  no  outward  signs  of  mental  disturbance  or  impairment, 
yet  the  conclusion  that  impairment  actually  existed  cannot  be  ex- 
cluded. The  impairment,  though,  would  seem  to  be  due  to  what 
we  have  learned  to  call  a  "  sphtting  of  the  personality"  rather 
than  to  any  permanent  destruction  of  mental  elements  (plus 
organic  changes  in  the  brain  of  a  degenerative  nature)  to  which 
the  term  dementia  could  properly  be  applied. 

The  weakness  of  judgment  that  is  called  paranoiac  is  not  one 
that  appears  to  be  equally  diffused  over  the  entire  field  of  the 
mental  operations.  It  seems  to  be  more  or  less  closely  associated 
with  a  definite  delusional  system.  We  must  not  on  that  account 
come  too  speedily  to  the  old  conclusion  that  a  person  may  be 
insane  on  one  subject  and  sane  on  all  others.  It  is  true  the 
reasoning  termed  paranoiac  often  seems  clear  on  subjects  not  con- 
nected with  the  specific  complexes,  but  we  must  not  lose  sight 
of  the  fact  that  the  delusion  itself  does  not  constitute  the  mental 
disorder — it  is  only  one  of  its  outward  and  manifest  expressions. 
In  this  respect  Mercier's^  comparison  of  a  delusion  to  an  island 
in  the  ocean  is  very  apt.  The  island  seems  to  occupy  a  position 
completely  isolated,  surrounded  on  all  sides  by  water,  but  if  the 
depths  of  the  ocean  be  sounded  it  will  be  found  that  it  is  in  reality 
but  the  summit  of  a  mountain  which  reaches  down  into  the  depths 
of  the  sea  to  its  very  bottom  and  so  establishes  a  connection  by 
direct  continuity  with  the  mainland.  So  with  a  delusional  system 
or  idea,  its  isolation  is  only  apparent,  in  reality  it  springs  from  the 
very  foundations  of  the  mental  life.  Paranoia,  from  this  angle, 
might  then  be  termed  a  "  circumscribed  psychoses  "  rather  than 
a  monomaina  in  the  sense  of  a  disorder  related  to  a  single  sub- 
ject.    The  delusional  elaborations  really  have  their  roots  deep 

2  Mercier,  Charles :  Criminal  Responsibility,  1905. 


PARANOIA  AND  PARANOID  STATES.  89 

in  the  personality  but  at  the  surface  the  disturbance  is  concen- 
trated in  a  comparatively  circumscribed  area. 

In  addition  to  the  characteristic  feature  which  will  be  termed 
paranoia,  which  has  just  been  discussed,  some  observers  would 
exclude  all  emotional  disturbances  other  than  could  be  directly 
attributed  to  the  delusions  present.  Wernicke^  maintains  this 
general  position  by  setting  forth  that  while  the  content  of  thought 
is  disordered,  the  form  of  thought  or  the  process  of  thinking  is 
preserved. 

This  theory  of  the  disease  harks  back  to  the  "  faculty  con- 
cepts "  of  the  old  psychology.  If  the  thesis  of  the  continuity  of 
mental  processes  that  I  have  maintained  in  the  early  part  of  this 
work  is  true,  then  such  a  state  of  affairs  could  hardly  be  con- 
ceived of  as  possible.  As  a  matter  of  fact,  the  thing  that  has 
happened  is  a  displacement  of  affect  which  gives  this  outward 
appearance  to  the  disorder. 

The  symptoms  of  the  early  stages  culminating  in  the  systema- 
tized delusions  of  persecution  are  symptoms  which  lead  up  to  and 
develop  what  is  best  described  as  the  paranoiac  character.  This 
paranoiac  character  is  a  character  the  essential  trait  of  which  is  a 
general  feeling,  mood,  or  as  it  is  sometimes  called  affect-tone  of 
suspicion.  It  is  closely  related  to  the  ego  complexes  of  the  in- 
dividual. If  the  wave  of  consciousness  is  conceived  of  as  occur- 
ring in  a  sea  of  feeling,  of  affects,  then  it  can  be  understood  how 
all  of  the  perceptions  of  the  outer  world,  received  and  bathed  in 
this  sea,  must  be  affected  by  its  nature.  If  the  mood  is  one  of 
suspicion,  then  all  the  experiences  of  life  are  contaminated,  and 
the  world  at  large  is  only  interpreted  as  the  perceptions  of  that 
world  are  tinctured  by  the  predominant  mood.  The  internal 
mental  state  is  projected  upon  the  environment. 

x\fter  all,  it  is  the  "  feeling-mass  "  more  than  the  intellectual 
processes  that  goes  to  make  up  character,  and  the  paranoiac  char- 
acter is  what  it  is  because  this  feeling-mass  has  become  perverted. 
Pratt*  has  well  said :  "  For  it  is  feeling  alone  that  gives  value  to 
life.  Sensation  and  ideation  merely  report  on  the  facts.  If  man 
were  only  a  cold  intellect  who  saw  and  judged,  one  thing  would 

3  Wernicke :   Grundriss  der  Psychiatric. 

•*  Pratt,  J.  B. :  The  Place  and  Value  of  the  Marginal  Region  in  Psychic 
Life,  The  Psychological  Review,  Jan.,  1906. 


90  OUTLINES   OF   PSYCHIATRY. 

be  to  him  as  valuable  as  another — in  fact  for  him  there  would 
be  no  values  in  the  universe  but  only  truths.  It  is  only  because 
man  has  feelings,  emotions,  impulses,  that  anything  in  heaven  or 
earth  has  value.  Moreover,  not  only  does  the  feeling  back- 
ground create  values;  it  also  is  often  that  part  of  a  man's  mental 
make-up  which  for  others  has  value.  What  we  love  in  our 
friend  is  not  his  sensations,  nor  chiefly  his  ideas  and  his  reason- 
ing power ;  it  is  principally  that  combination  of  indefinable  psychic 
qualities — impulses,  desires,  likes  and  dislikes — which  we  call 
his  disposition.  So  far,  then,  is  the  feeling-mass  from  being 
something  which  a  man  should  hope  in  the  course  of  evolution 
to  get  rid  of,  that  as  a  fact,  if  he  should  get  rid  of  it,  no  one 
would  be  able  to  find  anything  lovable  in  him,  and  he  hihiself 
would  be  utterly  unable  either  to  love  or  even  to  value  anything. 

"  In  short,  the  feeling-mass  is  wider  than  the  other  departments 
of  psychic  life,  and  more  closely  identified  with  the  self.  A 
change  in  it  means  a  change  in  personality.  Sensations  and  ideas 
have  a  communicable  and  universal  nature;  this  irrational  resid- 
uum is  peculiarly  private  and  individual.  It  is  the  determinant 
of  character — in  one  sense  it  is  the  character  and  the  personality. 
From  it  the  practical  activity  gets  most  of  its  energy  and  most  of 
its  guidance." 

BiANCHi^  would  create  the  disorder  on  the  basis  of  what  he 
terms  the  primitive  emotions — suspicion,  ambition,  love — which 
determine  the  three  classic  varieties:  the  persecutory,  the  am- 
bitious or  proud,  and  the  erotic.     He  says  on  this  point : 

"In  paranoia  the  fundamental  emotions,  which  are  also  an 
expression  of  the  altered  kinesthesis,  are  emotions  of  a  primitive 
character,  such  as  suspicion,  vanity,  pride  and  fear — fear  of  injury 
and  destruction,  desire  of  exaltation  and  of  grandeur  of  one's 
own  ego.  Therein  lies  the  reason  of  the  egocentric  attitude  of 
the  paranoic  subject  (Specht).  These  primitive  emotive  states, 
intrinsic  to  the  personality  and  proportioned  differently  in  different 
men,  determine  currents  and  orders  of  ideas  and  actions  in  the 
evolution  of  the  personality,  which  succeed,  in  various  ways,  in 
protecting  or  expanding  the  personality  in  a  rigorously  logical 
fashion.    When  those  emotive  states  exceed  the  normal  measure 

6  Bianchi,  L. :  A  Text-Book  of  Psychiatry.  New  York,  William  Wood 
&  Co.,  1906. 


PARANOIA   AND   PARANOID   STATES.  9 1 

in  intensity  and  persistence,  they  exercise  an  absolute  dominion 
over  the  consciousness,  until,  through  their  having  once  assumed 
government  over  the  senses  and  the  intellect,  there  is  an  altera- 
tion of  the  perception  and  the  apperception  processes  that  insure 
normal  relations  between  the  individual  and  his  environment." 

The  Paranoia  of  Magnan,  Krafft-Ebing,  and  Kraepelin. — ^The 
conception  of  paranoia  has  been  dominated  for  many  years  by  the 
descriptions  of  Magnan  in  France,  and  Krafft-Ebing  in  Aus- 
tria. Magnan's^  delire  chronique  a  evolution  systematique  is  a 
disease  which  usually  occurs  in  young  adults  who  quite  often,  if 
their  history  is  carefully  taken,  have  shown  peculiarities  during 
their  childhood,  manifesting  themselves  in  a  certain  taciturnity, 
moroseness,  or  disinclination  to  associate  with  other  children  as 
freely  as  is  usual.  The  child  may  also  have  shown  a  tendency  to 
make  friends  with  older  persons,  stay  at  home  and  read  and  sew 
instead  of  play,  and  may  have  had  a  tendency  to  day-dreams  and 
the  building  of  air-castles.  Very  often,  however,  the  history  ob- 
tained will  show  none. of  these  peculiarities. 

For  the  purpose  of  description  the  disease  may  be  divided  into 
three  stages,  named  in  accordance  with  their  most  characteristic 
sypmtoms.  First,  the  hypochondriacal  stage  or  stage  of  sub- 
jective analysis.  Second,  the  stage  of  persecution.  Third,  the 
stage  of  transformation  of  the  personality. 

In  the  first  stage  the  symptoms  already  described,  if  present, 
become  more  marked,  the  patient  becomes  wrapped  up  in  his 
own  thoughts  and  uncommunicative,  unusual  feelings  occur,  head- 
aches, dizziness,  weakness,  perhaps  insomnia,  with  nervousness 
and  restlessness,  which  he  fails  to  understand,  but  constantly 
worries  about — hypochondriacal  ideas.  This  condition  is  asso- 
ciated with  marked  emotional  depression,  which  in  some  degree 
is  probably  always  incident  to  beginning  paranoia.  He  soon 
begins  to  notice  that  people  act  differently  towards  him,  when  he 
goes  in  a  room  someone  gets  up  and  goes  out,  people  on  the  street 
spit  when  they  pass  him,  his  employer  has  failed  to  say  "good- 
morning  "  to  him  lately,  people  who  are  standing  about  here  and 
there  are  talking  about  him  and  speaking  of  his  condition  and 
making  disparaging  remarks.  Everything  that  occurs  about  him 
is  interpreted  as  having  some  relation  to  himself — ideas  of  refer- 

^  Magnan  et  Serieux :  Le  Delire  Chronique  a  fivolution  Systematique. 


92  OUTLINES   OF   PSYCHIATRY. 

ence.  This  condition  continues,  becomes  more  aggravated,  the 
ideas  are  not  corrected  and  the  patient,  by  keeping  by  himself, 
fails  to  come  into  that  normal  touch  with  the  environment  which 
gives  to  acts  and  circumstances  their  proper  perspective. 

The  hypohondriacal  ideas  and  ideas  of  reference  become  more 
constant  and  pronounced,  the  patient  fears  he  is  losing  his  reason, 
his  health  is  being  destroyed,  and  all  for  what  purpose?  what  is 
the  explanation  of  these  conditions?  why  do  people  act  towards 
him  as  they  do? 

The  second  stage  of  the  disease  is  ushered  in  by  the  delusion 
of  persecution,  which  is  the  patient's  answer  to  all  these  queries 
by  finding,  as  he  believes,  that  their  explanation  lies  in  the  opera- 
tion of  some  malign  influence  against  him.  About  this  time  also 
hallucinations  of  hearing  appear.  Heretofore  the  patient  may 
have  thought  persons  standing  apart  were  talking  or  whispering 
about  him,  or  may  have  heard  remarks  made  about  him  by  persons 
who  passed  him  on  the  street,  but  it  is  quite  impossible  to  tell 
whether  these  were  true  hallucinations  or  merely  falsely  in- 
terpreted occurrences.  Now,  however,  there  is  no  longer  any 
doubt;  the  patient  hears  actual  voices  which  usually  make  dis- 
paraging remarks  about  him  or  even  say  grossly  insulting  and 
vulgar  things  to  him. 

The  delusion  of  persecution,  reinforced  by  the  hallucinations 
of  hearing,  from  now  on  occupies  more  and  more  the  focus  of 
consciousness.  It  becomes  more  and  more  definite,  the  malign 
influence  is  recognized  as  an  organized  attempt  on  the  part  of 
a  secret  society,  perhaps  the  Free  Masons,  the  Jesuits,  the  Mafia, 
the  Catholic  Church,  headed  by  the  Pope.  The  agents  of  the 
society  are  always  near  him  and  the  many  annoyances  he  suffers 
are  the  results  of  their  machinations.  They  poison  his  food, 
inject  noxious  vapors  into  his  room  at  night,  send  electric  currents 
through  him  when  he  goes  to  bed,  bawl  all  sorts  of  insults  in  his 
ears  and  in  innumerable  ways  annoy  him  and  try  to  end  his  life. 
New  sensations  and  experiences  are  explained  by  some  new  device 
invented  to  torture  him — delusions  of  explanation,  and  various 
occurrences  going  on  about  him  are  similarly  woven  into  the  warp 
and  woof  of  his  delusional  system. 

The  delusions  are  now  almost  constantly  dwelt  on  to  the  ex- 
clusion of  everything  else,   everything  in  life,  every  conscious 


PARANOIA   AND   PARANOID   STATES.  93 

experience,  falls  into  some  relation  with  the  central  thought,  the 
delusions  are  fully  systematized,  they  have  reached  out  their  in- 
fluences like  the  tentacles  of  an  octopus  throughout  the  mental 
life  of  the  patient  and  exact  their  tribute  of  his  every  thought. 
During  all  this  period  of  development,  with  the  exception  of  the 
incipient  stages,  however,  there  has  been  very  little  emotional 
abnormality.  The  only  emotional  disturbances  are  those  natu- 
rally incident  to  the  character  of  the  delusions,  such  as  anger, 
vexation  and  the  like. 

At  first  the  patient  flees  from  his  persecutors,  going  from 
place  to  place  in  his  endeavor  to  escape,  and  finds  temporary 
relief  in  each  new  place  for  a  time  until  his  enemies  find  him 
out.  Keeping  this  up  for  a  while  until  he  finds  it  futile,  he 
endeavors  to  protect  himself  from  them  and  gets  up  all  sorts  of 
elaborate  devices,  depending,  of  course,  upon  the  character  of 
the  delusion.  The  key-hole  and  the  cracks  about  the  door  and 
windows  are  stuffed  with  papers,  the  bed  insulated  by  having  the 
legs  set  in  dishes  of  water,  the  food  carefully  tasted  and  often 
discarded.  Finally,  all  these  means  failing,  in  sheer  desperation 
and  driven  almost  frantic  by  the  continuous  persecutions,  he  turns 
upon  the  attacks  his  supposed  enemies.  Magnan  speaks  of  these 
three  stages  by  saying  that  at  first  he  flees,  then  defends  himself 
and  finally  attacks.     (II  fuit;  il  se  defend ;  il  attaque.) 

During  this  period  of  persecution  the  patient,  when  speaking 
of  his  persecutors,  at  first  uses  the  pronoun  "  they."  He  is  no 
more  specific  than  this,  but  finally  he  may  learn  exactly  who  are 
at  the  bottom  of  all  his  troubles.  When  he  finds  this  out  he  at 
once  becomes  a  dangerous  lunatic,  liable  at  any  time  to  acts  of 
violence  of  a  homicidal  character.  These  patients  belong  to  the 
most  dangerous  class  with  whom  we  have  to  deal,  especially  be- 
cause of  the  retention  of  their  intellectual  faculties. 

After  this  condition  has  continued  indefinitely  the  third  stage 
of  the  disease  may  supervene.  The  patient  develops  ideas  of  self- 
importance.  These  ideas  may  come  about,  according  to  Magnan. 
in  one  of  three  ways.  First,  spontaneously.  Second,  through  the 
mediation  of  the  hallucinations — the  voices,  for  example,  telling 
the  patient  that  he  is  some  great  personage.  Third,  as  the  result 
of  logical  deduction — if  so  many  people,  such  powerful  organiza- 
tions are  interested  in  his  downfall  he  must  indeed  be  some  great 


94  OUTLINES   OF    PSYCHIATRY. 

personage,  rightful  heir  to  a  throne,  or  inheritor  of  vast  estates. 
The  development  of  this  idea  of  self-importance,  noble  descent 
and  the  like  constitutes  the  transformation  of  the  personality  char- 
acterizing the  third  stage  of  the  disease. 

As  completely  as  the  delusion  of  persecution  occupies  the  field 
of  consiousness  at  this  time  and  as  thoroughly  as  it  may  be 
systematized,  we  find  in  this  as  well  as  in  the  second  stage  still 
further  evidences  of  elaboration  of  the  false  beliefs,  with  their 
projection  into  the  past  life  of  the  patient  even  as  far  back  as 
his  childhood — retrospective  falsifications.  In  the  light  of  the 
recently  acquired  facts  many  experiences  of  his  early  life,  which 
heretofore  have  seemed  mysterious,  find  their  explanation.  His 
so-called  parents  are  not  his  true  parents,  and  he  knows  now 
that  the  strange  woman  who  used  to  visit  the  house  and  always 
kept  her  face  heavily  veiled  must  have  been  the  emissary  of  his 
royal  father — retrospective  explanatory  delusion.  The  whispered 
conversation  of  his  parents  after  these  visits  had  reference  to  him, 
and  the  glances  of  the  servants  showed  that  they  suspected  some- 
thing strange  about  him — retrospective  ideas  of  reference.  Often 
the  patient  recalls  remarks  that  were  never  made,  occurrences  that 
never  happened  in  further  support  of  his  false  beliefs — retrospec- 
tive falsification  of  memory. 

With  the  development  and  elaboration  of  these  ideas  of  self- 
importance  the  general  attitude  and  appearance  of  the  patient 
change.  From  being  suspicious,  resentful,  irritable  and  antago- 
nistic, he  becomes  more  complacent  and  self-satisfied.  He  is  a 
great  personage  who  will  shortly  be  proclaimed  as  such  to  the 
world.  Often,  too,  he  will  tell  at  great  length  of  the  various 
methods  used  by  his  persecutors,  only  to  show  his  wonderful 
sagacity  and  prowess  in  defeating  their  ends. 

This  transformation  of  the  personality  is  the  natural  result  of 
what  has  gone  before.  We  have  traced  our  hypothetical  case 
through  the  hypochondriacal  stage  of  disorder  of  the  somato- 
psychic consciousness  and  seen  in  the  second  stage  the  systema- 
tized delusion  of  persecution  gradually  grow  from  an  insignificant 
begininng  to  a  state  in  which  it  dominates,  to  the  practical  exclu- 
sion of  everything  else,  the  consciousness  of  the  individual.  This 
delusion  involves,  in  the  main,  the  allopsychic  consciousness.  It 
is  not  strange,  then,  that  the  remaining  sphere  of  the  autopsychic 


PARANOIA   AND   PARANOID   STATES.  95 

consciousness  should  finally  be  encroached  upon.  (See  Chapter 
VII.    Transformation  of  the  Personality.) 

This  description  of  what  Magnan  and  his  followers  meant  by 
paranoia  would  indicate  a  degree  of  regularity  and  definiteness 
in  its  evolution  that  the  facts  rarely  warrant.  In  certain  in- 
dividuals such  an  evolution  may  become  stationary  at  any  point 
and  the  third  stage  in  many  cases  is  never  reached.  The  symp- 
toms of  the  first  stage  are  found  in  the  second,  and  these  in 
turn  in  the  third,  although  here  the  general  mood  and  ideas  of 
self-importance  may  dominate  the  picture.  The  development  and 
elaboration  of  the  disease  is  by  a  continuous  addition  rather  than 
a  substitution  or  modification  of  symptoms. 

The  fourth  and  final  stage  of  the  disorder  is  that  of  progressive 
mental  enfeeblement — the  stage  of  dementia. 

The  disease,  instead  of  running  the  regular  course  above  de- 
scribed, may  show  certain  variations.  Aside  from  becoming 
arrested  at  any  given  point,  as  already  mentioned,  the  principal 
one  is  the  early  appearnce  of  ideas  of  self-importance  which  may 
even  occur  contemporaneously  with  those  of  persecution.  Ordi- 
narily, however,  the  several  varieties  are  clinically  differentiated 
because  of  the  special  content  of  the  delusional  system. 

The  following  case  report  gives  an  account  of  this  form  of 
paranoia.  It  shows  the  early  disordered  sensations,  the  delu- 
sional interpretations,  the  hallucinations  and  the  ideas  of  grandeur. 
The  patient  is  a  young  man  recently  come  to  this  country. 

Five  years  ago  in  1907,  patient  had  sensations  of  a  worm  crawling  up 
into  his  throat,  tickling  his  palate.  This  worried  him  a  great  deal,  so 
he  consulted  an  apothecary  who  gave  him  a  dose  of  medicine  with  the 
idea  of  ridding  him  of  this  worm.  However,  he  believes  that  this  worm 
may  have  been  but  an  evil  spirit  which  was  put  into  him  to  give  him  an 
inspiration.  This  worm  continued  to  bother  him  with  disagreeable  sensa- 
tions in  bis  throat  until  1910,  when  after  completing  a  series  of  six  letters, 
written  to  one  of  the  London  daily  papers,  and  only  one  of  which  was 
published,  he  was  no  longer  bothered  by  the  worm  and  it  seems  to  him 
that  this  worm,  after  having  accomplished  its  object,  that  is  inspiring 
him  to  write  these  letters,  was  killed  within  his  chest  by  some  mysterious 
force,  perhaps  an  Angel  of  God.  These  six  letters  which  he  wrote  to  the 
London  paper  dealt  with  the  subject  of  "Why  men  no  longer  marry." 
The  two  great  arguments  he  mentions  are  prostitution  and  the  fact  that 
women  are  taking  men's  places  in  the  business  world,  thus  reducing  their 
salaries.    An  angel  has  been  appearing  to  him  about  once  a  week,  seeming 


g6  OUTLINES   OF   PSYCHIATRY. 

to  suggest  various  things  in  connection  with  his  thoughts  and  to  impress 
upon  him  what  is  wrong  and  what  is  right.  Ofttimes  she  has  spoken  a 
few  words,  but  she  communicates  with  him  mostly  by  gesture  and  signal. 
On  November  i8,  191 1,  while  asleep,  he  felt  a  tapping  on  his  shoulder, 
and  heard  a  voice  repeat  over  and  over,  "You  are  God."  He  awoke  at 
the  last  tap  on  his  shoulder  and  heard  the  voice  for  the  last  time  say, 
"  You  are  Grod."  Since  that  time  he  has  written  letters  to  Mr.  Hearst, 
editor  of  the  New  York  American,  about  the  Millennium,  incorporating  in 
his  article  the  idea  that  every  member  of  a  community  should  be  nour- 
ished through  the  medium  of  currency  just  as  each  member  of  the  body 
is  nourished  with  blood,  and  that  everyone  should  be  a  civil  servant,  that 
is  in  the  civil  service.  On  January  22,  1912,  he  wrote  a  letter  to  Presi- 
dent Taft,  the  subject  of  which  was  "Kingdom."  In  this  letter  he  stated 
that  he  believed  himself  to  be  Christ  in  his  second  appearance  on  earth. 
On  January  24,  1912,  the  evening  before  he  came  to  Washington  to  see 
the  President  because  he  had  not  received  an  answer  to  his  letter  nor  had 
it  been  sent  back  as  he  had  requested,  he  had  a  dream;  in  this  dream  he 
saw  an  angel  lying  upon  a  bed;  he  heard  her  speak  to  him,  saying,  "If 
you  go  across  the  street  and  get  me  a  nice  brown  cake,  you  may  lie  with 
me."  This  dream  seemed  to  be  a  revelation  to  him.  The  angel  signified 
the  American  people  as  they  are  represented  in  the  Statue  of  Liberty  and 
Columbia.  Buying  the  cake  meant  the  outlay  of  money  which  would  be 
necessary  in  his  trip  to  Washington  to  see  the  President.  Lying  with 
her  meant  his  acceptance  by  the  American  people,  as  Christ. 

Krafft-Ebing''  first  considers  paranoia  under  two  great  heads, 
which  are  classified  as  early  or  original  paranoia,  beginning  even 
in  childhood,  and  late  or  acquired  paranoia,  beginning  late  in  life. 
Original  paranoia  occurs  only  in  patients  with  very  marked  hered- 
itary taint,  and  as  Sander — who  originally  used  this  term — most 
admirably  expresses  it,  the  abnormal  condition  develops  and  un- 
folds itself  in  the  same  way  that  the  normal  mind  develops  and 
unfolds  itself  in  the  normal  individual.  Acquired  paranoia,  on 
the  other  hand,  develops  in  an  individual,  who,  except  for  his 
hereditary  taint,  may  appear  to  be  a  normal  person.  While  in 
late  paranoia  there  is,  as  we  have  seen,  a  transformation  of  the 
personality,  a  change  in  the  individual  wrought  by  the  disease 
process ;  in  original  paranoia  there  is  not  a  transformation  but  an 
unfolding  of  a  personality  which  is  from  the  beginning  patho- 
logical. A  further  general  subdivision  of  cases  is  based  on  the 
presence  or  absence  of  hallucinations.     So  we  have  paranoia  hal- 

''^  Krafft-Ebing,  R.  von:  Text-Book  of  Insanity.  Philadelphia,  F.  A. 
Davis  &  Co.,  1904. 


PARANOIA   AND   PARANOID   STATES.  9/ 

lucinatoria,  in  which  the  hallucinations  play  a  prominent  part  in 
the  elaboration  of  the  delusional  system,  and  paranoia  combina- 
toria,  in  which  hallucinations  do  not  occupy  a  prominent  place  or 
are  altogether  absent,  the  delusional  system  growing  on  the  basis 
of  idea-association. 

The  late  or  acquired  paranoia  is  subdivided  into  two  great 
groups,  those  in  which  the  delusions  of  persecution  are  the  most 
prominent  features  would  be  classed  as  persecutory  paranoia, 
while  those  in  which  grandiose  ideas  predominated  would  be 
classed  as  expansive  paranoia.  In  the  former  group  is  included 
the  querulous  or  litigious  variety  which  by  some  is  considered  to 
occupy  a  position  midway  between  the  original  and  acquired,  and, 
like  the  original,  hallucinations  do  not  play  a  prominent  part  in 
its  evolution,  and  also  like  the  original,  the  delusions  often  contain 
elements  of  truth  and  often  develop  on  the  basis  of  some  actual 
occurrence,  more  particularly  the  loss  of  some  law  suit.  They 
are  notable  not  only  because  of  their  apparent — in  fact  their  real — 
adherence  to  facts,  but  for  their  convincing  character. 

The  latter  group  includes  that  host  of  unbalanced  dreamers 
who  are  frequently  known  as  "  cranks,"  and  who  may  be  further 
classified  on  the  basis  of  the  content  of  their  delusional  system 
into  inventive,  reformatory,  religious  and  erotic  varieties.  These 
patients  have  made  some  wonderful  invention,  are  destined  to 
carry  on  great  reforms,  are  the  vicegerent  of  God,  or  believe  them- 
selves beloved  by  some  loyal  person.  The  following  is  a  case  of 
so-called  erotic  paranoia  in  which  the  erotic  projections  were 
prominent. 

Family  history  shows  nothing  worthy  of  note.  Patient's  early  child- 
hood presents  no  abnormalities.  He  had  a  common  school  education.  At 
the  age  of  ten,  he  had  quite  a  severe  illness.  While  working  on  his 
father's  farm  he  conceived  the  idea  of  becoming  an  inventor,  which  his 
folks  discouraged  so  greatly  that  he  left  home  and  went  to  Chicago,  where 
he  worked  as  hostler  and  coachman,  giving  excellent  service.  In  1899, 
he  obtained  his  first  patent,  it  being  for  a  special  bicycle  hub.  In  con- 
nection with  his  attempts  to  make  this  patent  a  financial  success,  he  first 
showed  ideas  which  might  be  termed  paranoid.  The  man  to  whom  he 
gave  a  half  interest  in  his  patent  failed  to  manipulate  the  stock  of  the 
company  which  was  incorporated  in  proper  manner,  and  the  people  who 
became  interested  in  his  proposition  he  thinks  were  mostly  sent  by  other 
manufacturers  to  discourage  him  in  his  attempts  to  make  something  out 
of  it.     In  1906,  he  patented  a  brush  which  he  induced  the  Pullman  car 


98  OUTLINES  OF   PSYCHIATRY. 

people  to  try,  but  they  were  not  a  success  because  of  the  activities  of  the 
whisk  broom  manufacturers,  who,  in  league  with  the  porters,  caused  them 
to  be  returned  as  defective.  He  has  continued  up  to  the  present  time 
manufacturing  these  brushes  in  a  small  way,  and  devoting  his  time  to 
perfecting  machines  in  order  to  increase  their  output.  According  to  his 
statements  he  has  a  financial  rating  of  $1,000,  and  says  he  would  have 
more  money  had  he  not  spent  so  much  in  models  for  his  machinery. 
Among  the  pamphlets  which  he  has  gotten  out  for  advertising  purposes, 
was  one  dealing  with  American  wealth  marrying  foreign  titles,  which  he 
wrote  about  the  time  Miss  Katherine  Elkins  and  the  Duke  of  Abruzzi 
were  prominent  names  in  newspaper  headlines.  With  this  article  he  had 
his  picture  published,  one  taken  about  fifteen  years  ago,  when  he  said  he 
was  a  very  handsome  man.  He  denies  the  use  of  drugs,  and  rarely  takes 
a  drink.    He  masturbates  at  least  once  a  week,  and  sometimes  oftener. 

About  three  years  ago  while  visiting  in  Washington,  he  dropped  into  the 
National  Museum  to  look  over  some  propeller  models.  He  believes  that 
Miss  Katherine  Elkins  entered  the  building  carrying  a  coronet  in  her 
hand ;  that  upon  seeing  him,  she  said,  "  There  is  the  man  who  caused  me 
to  do  this.  He  is  not  so  handsome  as  his  pictures,  but  his  writings  are 
so  penetrating."  From  this  statement,  he  became  convinced  that  Miss 
Elkins  had  obtained  one  of  his  pamphlets,  had  seen  his  handsome  picture, 
and  as  a  result,  had  broken  off  her  engagement  with  the  Duke.  A  short 
time  later,  he  saw  her  again  in  his  Chicago  bank,  motioning  to  him  to 
come  to  her.  A  year  later  while  in  Washington,  he  again  saw  her  in  a 
carriage  on  Penna.  Avenue.  He  heard  her  call  to  him.  Once  while  walk- 
ing along  a  street  in  Chicago,  her  sudden  appearance  before  him  he  be- 
lieves to  have  saved  his  life,  as  it  caused  him  to  halt,  just  as  a  man  fell 
from  a  ten-story  building  to  the  pavement  at  his  feet.  A  short  time  later, 
he  saw  her  walking  along  the  street,  and  heard  her  say  to  a  woman  com- 
panion, "I  do  not  object  to  him  because  he  is  poor."  Sometime  this  last 
summer,  a  somewhat  cultured  looking  old  man,  purposely  dressed  rather 
shabbily  he  thinks,  came  to  room  with  the  janitor  of  the  boarding  house, 
directly  across  the  hall  from  his  room.  He  believes  that  this  old  man 
and  several  others  who  stayed  a  shorter  time,  were  agents  sent  by  the 
grandfather  of  Miss  Elkins  to  observe  his  life.  Of  this  he  was  rather 
glad,  for  he  wanted  the  Elkins  family  to  know  that  he  lived  a  clean, 
irreproachable  existence.  Ever  since  the  occurrence  at  the  National 
Museum,  he  has  written  quite  regularly  to  Miss  Elkins,  and  because  he 
has  received  no  reply  requesting  that  he  cease  doing  so,  believes  she  gave 
her  consent  to  his  correspondence.  When  about  a  year  ago  he  called  at 
the  Elkins'  home,  to  see  Miss  Elkins,  and  was  rather  brusquely  turned 
away,  he  conceived  the  idea  that  the  family  knew  of  her  love  for  him, 
and  was  attempting  to  keep  her  from  seeing  him.  Sometime  this  fall, 
intending  to  make  his  annual  trip  to  Washington,  he  wrote  a  letter  pro- 
posing to  Miss  Elkins,  and  on  his  arrival  in  the  city  went  to  her  home 
on  K  Street  to  have  the  matter  settled  one  way  or  the  other.    However, 


PARANOIA   AND    PARANOID   STATES.  99 

when  he  called  at  her  home,  he  was  requested  to  call  that  afternoon. 
During  the  day,  he  busied  himself  talking  with  a  patent  attorney  on  the 
advisability  of  patenting  a  model  which  he  had  constructed  demonstrating 
that  the  earth's  axis  is  horizontal  instead  of  perpendicular.  When  he  went 
for  his  noonday  lunch,  he  had  to  wait  so  long  for  what  he  had  ordered, 
that  he  believed  that  he  must  have  been  doped  by  parties  who  were  bent 
upon  preventing  him  seeing  Miss  Elkins.  When  he  returned  to  the  Elkins' 
residence,  he  was  adroitly  conducted  to  the  police  station.  He  was  taken 
to  th€  Washington  Asylum  Hospital,  where  he  saw  Miss  Elkins  come  in  to 
lead  him  out;  he  is  sure  it  was  she  by  the  warmth  of  her  hand. 

Medical  certificate  states  that  patient  is  not  addicted  to  the  use  of 
narcotics.  The  first  symptoms  became  manifest  by  patient  requesting  pro- 
tection from  the  Attorney  General  for  his  patent  rights.  Present  symp- 
toms :  Patient  says  he  has  a  patent  for  making  brushes  and  that  they  are 
so  good  and  so  widely  used,  that  the  other  manufacturers  are  jealous  and 
attempt  to  harm  him.  They  go  around  quietly  and  destroy  his  brushes. 
He  has  made  a  model  of  the  earth  and  sun,  which  shows  that  the  present 
knowledge  of  astronomy  is  incorrect.  He  says  if  the  other  manufacturers 
got  a  chance,  they  would  do  him  bodily  harm.  He  says  his  patent  rights 
are  worth  from  one  to  five  million  dollars.  He  has  also  invented  a  patent 
flying  machine  which  is  altogether  different  from  any  of  the  191 1  models. 
He  says  it  is  different  from  any  on  the  market.  He  has  also  invented  a 
motor  boat  propeller  which  is  a  great  improvement  on  the  existing  ones. 
Says  that  a  certain  party  is  having  him  watched.  This  man  is  jealous  of 
him  on  account  of  a  woman.  Says  he  is  the  best  inventor  living.  Says 
sometime  ago  he  wished  an  enemy  of  his  would  die,  and  he  died.  Saw 
a  vision.    No  homicidal  or  suicidal  tendencies. 

Since  patient  has  been  here,  and  thought  over  some  of  the  past  events, 
he  believes  that  a  man  who  came  to  visit  him  in  Chicago  put  some  dope  in 
the  cigar  which  he  was  smoking.  He  seems  much  concerned  as  to  the 
little  business  which  he  is  conducting  in  Chicago.  He  states  that  if  he 
were  free,  he  would  go  directly  there  and  not  return  to  Washington,  and 
drop  this  love  affair  entirely.  He  laughingly  states  that  the  idea  which  his 
model  illustrates  regarding  the  earth's  axis  will  some  day  be  taught  in 
the  public  schools,  and  it  will  be  said  that  he,  the  discoverer,  was  arrested, 
tried  and  adjudged  insane  the  first  day  he  presented  it. 

In  these  individuals  the  idea  of  self-importance  quite  obscures 
the  persecutory  ideas,  which,  if  they  are  present  at  all,  be- 
come a  negligible  quantity,  while  in  many  cases  they  are  not 
present  in  the  true  sense  of  the  term.  A  reformatory  paranoiac 
may  be  prevented  from  doing  as  he  wishes  by  the  civil  authori- 
ties, whereupon  he  believes  himself  persecuted,  but  this  is  not 
a  true  delusion  of  persecution  in  the  sense  this  term  has  been 
used  in  describing  paranoia.     When  such  patients  are  interfered 


lOO  OUTLINES  OF   PSYCHIATRY. 

with  they  usually  resent  it  and  often  rebel.  They  are  then  desig- 
nated as  persecuted  persecutors. 

This  whole  anomalous  group  of  paranoiac  psychoses  developing 
upon  a  markedly  predisposed  background,  in  individuals  of  a 
strong  hereditary  taint,  has  been  designated  by  the  French  as  the 
insanity  of  degenerates. 

Kraeplin's®  conception  of  the  paranoia  group  is  radically  dif- 
ferent. He  would  throw  all  of  the  cases  of  Magnan  and  many 
of  Krafft-Ebing  into  his  group  of  paranoid  dementia  precox 
while  the  rest  he  distributes  as  paranoid  states  as  occurring  in 
several  different  psychoses. 

For  him  hallucinations  are  excluded  from  the  picture,  in 
which  concept  he  diiTers  essentially  from  the  trend  taker  by 
Heinroth  and  his  followers.  The  disease  is  a  chronic,  incurable 
psychosis,  of  insidious  origin,  slowly  developing  by  the  gradual 
systematization  of  delusional  ideas  of  endogenous  formation. 
This  system  of  delusional  ideas  is  enduring  and  unshakable  and 
exists  along  with  retention  of  the  logical  and  orderly  process  of 
thinking  apart  from  the  specific  complexes.  There  is  no  tendpncy 
to  marked  mental  deterioration  (dementia). 

The  following  is  a  very  brief  summary  of  such  a  case.  It 
gives  quite  an  inadequate  idea  of  a  life  crowded  with  events 
growing  out  of  a  delusional  system  and  which  have  received  the 
most  complex  interpretation: 

White  male,  63  years  of  age;  admitted  April  6,  1910,  on  a  certificate 
which  stated  that  the  patient  was  taken  to  the  Washington  Asylum  Hos- 
pital on  March  7,  1910,  saying  he  had  been  hypnotized,  and  that  $36,000, 
which  had  been  sent  him  by  a  firm  in  Philadelphia,  had  been  stolen  from 
him.  He  had  been  in  what  he  called  a  hypnotic  state,  and  had  attracted 
considerable  attention  in  the  city.  While  he  was  in  the  Washington 
Asylum  Hospital  he  wrote  out  in  detail  his  life  history.     Briefly  summa- 

8  Kraepelin,  Emil :  Psychiatric.  In  the  eighth  edition  of  his  work  he 
has  tentatively  created  a  group — Paraphrenia — which  includes  the  dementia 
paranoides,  formerly  included  in  dementia  precox,  and  certain  other  para- 
noid states  which  do  not  show  the  characteristic  disorganization  of  the 
personality  and  the  defects  of  aflfect  and  will  of  the  precox  (see  Chap. 
XI).  The  main  disturbance  is  intellectual.  It  would  seem  that  this  group 
occupies  a  midposition  between  his  paranoia  as  described  above  and  the 
paranoid  types  of  precox.  He  subdivides  the  group  into  four  divisions, 
viz.,  paraphrenia  systematica,  paraphrenia  expansiva,  paraphrenia  confabu- 
latoria  and  paraphrenia  fantastica. 


PARANOIA   AND   PARANOID   STATES.  lOI 

rized  his  history  shows  that  he  has  grandiose  ideas,  which  are  based  upon 
what  he  claimed  was  an  original  discovery  with  him,  namely,  getting  gold 
out  of  sea  water,  and  also  extracting  gold,  by  his  special  electrolytic 
process,  from  auriferous  quartz.  He  claims  he  has  made  fabulous  sums 
by  these  means.  He  has  travelled,  according  to  his  statement,  over  the 
greater  part  of  the  world;  says  the  Jamison  Raid  and  Boer  War  were  the 
results  of  the  British  Government  attempting  to  stop  his  company's  pro- 
duction of  gold,  which  was  demorahzing  the  gold  standard.  He  gives  in 
detail  in  the  history  various  experiences  connected  with  his  delusions, 
which  are  evidently  falsifications.  He  states  that  twice  he  has  had  a 
period  of  loss  of  consciousness ;  once  in  1896  for  six  months,  and  recently, 
before  his  commitment  to  the  Washington  Asylum  Hospital.  His  first 
period  was  caused  by  a  blow  on  the  head,  inflicted  by  his  enemies  in  order 
that  they  might  secure  his  bank  books  which  contained  a  record  of  his 
enormous  holdings  in  various  banks  in  New  York,  which  money  he  had 
secured  through  his  gold-producing  efforts.  Each  time  he  was  brought 
out  of  his  period  of  loss  of  consciousness  by  a  hypnotist  named  Mark 
Tracey,  but  what  connection  Mark  Tracey  had  with  his  previous  life  has 
not  been  elaborated  by  the  patient.  For  the  past  three  years  he  has  been 
endeavoring  to  form  a  dairy  company  for  the  production  of  desiccated 
milk,  which  he  claims  will  prevent  the  sicknesses  of  children  which  have 
been  dependent  upon  impure  milk.  In  connection  with  the  formation  of 
this  company  he  came  to  Washington  to  purchase  various  farms.  He 
gives  in  detail  all  his  experiences  and  interpretations  in  his  autobiography 
— a  voluminous  document  consisting  of  many  closely  written  pages.  An 
examination,  however,  shows  that  he  has  but  a  meager  knowledge  of  the 
places  he  claims  to  have  visited,  and  it  is  evident  that  he  has  acquired 
his  knowledge  by  reading.  He  is  rather  an  eccentric  looking  man,  small, 
with  long  hair  and  shabby,  worn-out  clothing.  He  is  very  quiet,  has  not 
been  talking  about  his  ideas  with  the  other  patients,  but  has  a  few  times 
casually  mentioned  them  to  the  physicians;  when  questioned  regarding 
them  he  is  composed,  talks  in  a  moderate  tone,  and  would  not  impress 
one  as  being  especially  egotistical.  The  ideas,  however,  are  firmly  fixed, 
and  he  can  quite  readily  elaborate  them.  There  is  no  evidence  of  mental 
reduction. 

Delirium  of  Interpretation. — Serieux  and  Capgras"  have 
separated  from  the  great  paranoia  group  a  certain  number  of 
individuals  who  because  of  their  like  symptoms  and  course  they 
believe  belong  together  and  to  which  they  have  given  the  name 
of  delirium^"  of  interpretation. 

•  Serieux  et  Capgras :  Les  Folies  Raisonnantes.    Paris,  1909. 
1®  The  word  delirium  is  here  used  in  the  sense  given  it  by  the  French, 
namely,  to  apply  to  the  sum  of  the  patient's  delusional  experiences. 


102  OUTLINES   OF   PSYCHIATRY. 

The  characteristics^^  of  the  delirium  of  interpretation  are  that 
it  occurs  in  lucid,  constitutional  psychopaths,  not  mentally  en- 
feebled. The  affection  is  incurable,  and  is  characterized  by  a 
proliferation  of  delusional  interprettions  which  coordinate  them- 
selves into  a  system  more  or  less  coherent  without  notable  de- 
does  not  eventuate  as  a  consequence.  Unlike  some  other  paranoid 
throughout,  the  evolution  of  the  psychosis  takes  place  by  a 
progressive  extension  of  the  false  interpretations,  and  dementia 
does  not  eventuate  at  a  consequence.  Unlike  some  other  paranoid 
conditions  the  false  interpretations  take  their  origin  in  actual  facts. 
The  patient  because  of  his  constitutional  peculiarities,  lack  of 
critique  and  egocentricity,  arrives  at  false  interpretations  by  giving 
a  personal  meaning  to  everything  that  occurs. 

The  following  is  a  brief  summary  of  a  case: 

White  woman;  Z'2  years  of  age.  Father  sustained  a  cranial  injury, 
since  which  time  he  has  shown  symptoms  of  nervous  and  mental  derange- 
ment. Patient  was  an  eight  months'  baby.  The  history  of  her  childhood 
shows  nothing  noteworthy.  She  received  a  good  education.  Between  the 
ages  of  i8  and  21  she  did  housework  and  cared  for  her  mother,  who  was 
ill.  For  one  year  she  held  a  position  as  companion,  after  which  she 
studied  stenography  and  typewriting  for  six  months.  She  obtained  posi- 
tions paying  six  and  eight  dollars  a  week.  She  then  opened  an  office,  but 
v;as  handicapped  on  account  of  an  occupation  neurosis.  In  1905  she 
secured  a  Civil  Service  position  in  the  Government  Printing  Office,  which 
she  held  until  the  time  of  her  admission  at  the  Sibley  Hospital.  Compen- 
sation was  two  dollars  per  day.  She  suffered  from  lead  poisoning  while 
engaged  in  this  occupation.  She  claimed  to  have  been  persecuted  in  various 
ways  since  1908 — her  business  associates  made  uncomplimentary  remarks 
regarding  her;  the  men  of  her  acquaintance  made  improper  proposals  to 
her;  the  woman  with  whom  she  boarded  opened  her  mail  and  intercepted 
her  telephone  messages;  the  Catholics  molested  her  in  many  ways.  The 
latter  part  of  May,  1910,  she  was  visiting  some  relatives  in  the  country, 
having  left  the  city  to  avoid  further  molestations  from  her  persecutors. 
She  retired  early  one  night,  but  was  unable  to  go  to  sleep.  She  heard  men 
riding  past  her  window  on  horseback  and  saw  the  light  of  their  lanterns 
flashed  into  her  room.  About  midnight  she  heard  stealthy  footsteps  ap- 
proaching, and  the  mattress  was  rolled  up  over  her  feet.  When  she 
attempted  to  escape  a  strong  hand  seized  her  ankle.  A  struggle  ensued 
but  the  patient  escaped  through  the  window,  injuring  her  foot  in  the  fall. 
She  was  taken  to  Sibley  Hospital,  but  was  later  transferred  to  the  Wash- 

1^  Serieux  et  Capgras :  Diagnostic  du  Delire  D'lnterpretation,  Revue  de 
Psychiatric,  Jan.,  1908. 


PARANOIA  AND   PARANOID  STATES.  IO3 

ingfton  Asylum  Hospital,  from  which  institution  she  was  committed.  Her 
false  interpretations  are  very  extensive  and  elaborate.  For  example :  a 
young  woman,  a  switch  board  operator,  left  her  position  at  the  place  the 
patient  was  living.  She  immediately  elaborated  an  explanation,  that  she 
had  been  enticed  away  for  immoral  purposes  and  later  when  a  nearby 
building  burned  down  she  heard  a  scream  and  was  convinced  this  young 
woman  had  been  burned  to  death  in  the  building. 

Delirium  of  Revindication. — Serieux  and  Capgras  believe 
that  these  two  psychoses,  the  delirium  of  interpretation,  and  the 
delirium  of  revindication,  should  be  all  that  are  included  under 
the  term  paranoia. 

This  psychosis  may  be  defined  as  a  chronic  systematized 
psychosis  constituted  by  the  exclusive  predominance  of  a  fixed 
idea  which  imposes  itself  upon  the  mind  as  an  obsession.  It  is 
a  monoideism,  developing  in  degenerates,  and  does  not  end  in 
dementia. 

There  are  two  varieties  of  this  psychosis — the  egocentric  and 
the  altruistic.  Those  of  the  egocentric  type  are  usually  perse- 
cutors, enemies  of  society,  making  claims  for  wrongs  suffered 
that  may  or  may  not  have  some  foundation  in  fact.  Here  we 
find  the  litigants,  certain  not  understood  writers  and  artists,  cer- 
tain hypochondriacal  persecutors,  amorous  types,  etc.  In  the 
altruisic  variety  the  ideas  are  abstract,  the  theories  impersonal 
and  concern  science,  philosophy,  politics,  religion,  etc.  In  this 
group  are  found  the  inventors,  reformers,  prophets.  They  are 
dominated  by  altruistic  sentiments  and  far  from  being  persecutors 
are  often  generous  philanthropists.  Often,  however,  in  endeavor- 
ing to  realize  their  ideals,  they  become  dangerous  fanatics  of  all 
sorts — mystics,  anarchists,  regicides.  The  diversity  of  all  these 
forms  is  only  apparent.  There  exists  no  real  difference  between 
a  litigious  persecutor  and  the  searcher  for  the  philosopher's  stone. 
Their  psychoses  are  all  characterized  by  two  signs :  the  prevailing 
idea  and  the  mental  exaltation. 

The  following  is  an  example  of  the  egocentric  variety  of  this 
psychosis.  The  patient  belongs  to  the  querulous  or  litigant  type 
of  Krafft-Ebing.  He  is  an  old  negro  man,  a  veteran  of  the 
Civil  War. 

He  enlisted  in  the  fall  of  1863  in  the  29th  Illinois  Colored  Infantry  in 
Chicago.  Three  days  later  he  was  sent  on  to  Quincy,  111.,  160  miles  south 
of  Chicago.    They  went  into  camp  and  he  remained  there  until  May,  1864. 


104  OUTLINES   OF    PSYCHIATRY, 

At  that  time  the  soldiers  were  mustered  from  the  State  to  Federal  service. 
The  patient  was  the  captain  of  Company  F,  which  consisted  of  colored 
soldiers,  and  he  arranged  his  men  in  line  for  mustering.  It  was  the  custom 
for  the  captain  to  take  the  oath  before  the  men  did.  One  of  the  Federal 
officers  asked  the  patint  to  take  the  oath  of  allegiance  to  the  United 
States,  renouncing  his  allegiance  to  all  other  countries,  including  Canada, 
where  the  patient  had  been  born.  The  patient  said  that  at  that  time  he 
preferred  to  remain  a  subject  of  Britain  and  did  not  think  that  he  should  be 
forced  to  give  up  his  allegiance,  in  that  he  had  not  enlisted  under  any  such 
terms.  Thereupon  the  officer  refused  to  muster  the  company  in  but  allowed 
the  patient  to  remain  at  the  head  of  Company  F,  taking  charge  of  the  post 
at  Quincy,  Illinois.  The  patient  at  once  put  the  city  under  martial  law.  July 
l8,  1864,  the  company  was  sent  to  Chicago  and  was  then  requested  to  come 
to  Washington,  D.  C,  to  be  mustered  in.  Here  again  the  patient  refused 
to  take  the  oath  as  was  demanded  of  him  and  as  a  consequence  they 
arrested  him,  took  him  from  the  company  and  sent  him  to  prison  at  City 
Point,  Va.  After  being  confined  there  for  a  short  time  he  was  released, 
allowed  to  again  take  charge  of  the  company,  was  promised  pay  at  $100  a 
month  for  his  services  and  in  addition  was  not  required  to  take  the  oath 
of  allegiance.  He  says  that  he  never  received  any  pay  for  his  services. 
The  patient  let  the  matter  rest  until  1880,  thinking  that  rectification  would 
be  made  in  due  course  of  time  when  the  War  Department  would  discover 
the  injustice  that  had  been  done  him. 

In  1880,  under  Garfield's  administration,  patient  wrote  a  letter  to  Robert 
T.  Lincoln,  then  Secretary  of  War.  He  called  the  attention  of  the  Secre- 
tary to  his  (the  patient's)  case.  Mr.  Lincoln  gave  the  letter  to  John  Sher- 
man, then  Secretary  of  the  Treasury,  asking  the  latter  to  look  into  the 
facts  in  the  case.  Sherman  later  wrote  the  patient  that  he  acknowledged 
his  services  during  the  late  rebellion  but  that  he  had  lost  all  rights  for  the 
payment  of  services  on  the  ground  of  desertion.  The  patient  states  that 
his  early  refusal  to  give  up  his  allegiance  to  England  as  a  subject  of 
Canada  and  his  subsequent  arrest  and  release  had  unjustly  been  the  basis 
for  the  charge  of  desertion  preferred  against  him.  Patient  kept  up 
correspondence  with  Sherman  for  eighteen  months,  then  Sherman  asked 
him  to  make  a  full  statement  of  his  services  and  of  all  that  led  up  to  the 
charge  of  desertion.  In  reply  Sherman  stated  that  according  to  the  records 
of  the  War  Department,  the  patient  was  regularly  mustreed  in  the  service 
of  the  United  States  and  deserted  therefrom  at  Petersburg,  Va.,  in  the 
face  of  the  enemy  and  the  charge  of  desertion  that  rested  against  him  in 
the  War  Department  could  not  be  removed.  Patient  thereupon  asked  for 
the  copy  of  the  original  records.  Sherman  submitted  same.  Patient  sent 
the  copy  of  record  to  the  Secretary  of  War,  Lincoln,  asking  that  it  be 
submitted  to  a  Senate  Committee  for  consideration.  On  March  17,  1882, 
it  was  proven,  and  admitted  by  Secretary  of  the  Treasury,  Sherman,  be- 
fore the  Senate  Committee,  that  the  original  records  to  correspond  with 
the  copied  records  which  had  been  sent  to  the  patient  did  not  exist,  that 


PARANOIA   AND   PARANOID   STATES.  IO5 

the  charges  against  the  patient  were  not  sustained  and  that  Sherman  him- 
self admitted  that  he  had  acted  as  he  did  because  he  thought  that  he  was 
doing  the  best  for  the  Government.  The  patient  says  that  he  thinks  that 
Sherman  was  trying  to  beat  him  out  of  the  money  so  that  he  could  keep  it 
for  himself  and  that  this  was  one  of  the  main  charges  which  resulted  in  the 
removal  of  Sherman  from  his  position  as  Secretary  of  the  Treasury.  The 
patient  says  that  he  had  demanded  of  Sherman  $500,000  for  his  eleven 
months  of  service,  the  kidnapping  and  false  arrest  and  for  his  having 
been  put  back  into  the  service  without  being  regularly  mustered  into  the 
service  of  the  United  States.  The  patient  says  that  a  clerk  from  the  War 
Department  came  to  him  with  a  message  from  President  Garfield  and  that 
$275,000  was  offered  to  him.  He  accepted  the  same  and  was  told  to  wait 
until  they  sent  for  him.  He  waited  until  May  20,  1884,  and  then  sent  to  the 
War  Department  again  to  look  after  the  case.  Representative  McKinley 
(later  President)  took  the  matter  up,  showed  that  there  were  83,000  other 
men  on  similar  false  charge  of  desertion  and  by  Act  of  Congress  exon- 
erated them  all,  with  the  patient  at  the  head  of  the  list.  President  Arthur 
then  ordered  Secretary  of  War,  Lincoln,  to  give  the  patient  a  certificate  of 
exoneration  and  to  pay  over  to  him  the  sum  of  $500,000.  The  patient  does 
not  know  whether  Congress  had  passed  a  bill  to  that  effect  or  not.  He 
says  that  Lincoln  tried  to  put  up  a  job  on  him.  He  arranged  to  meet  the 
patient  at  the  Second  Precinct  on  U  St.  between  ninth  and  tenth,  saying 
that  he  wished  to  settle  the  matter  with  him  privately.  He  was  told  that 
he  was  to  be  sent  to  the  Government  boarding  house  for  a  few  days 
while  negotiations  were  going  on,  but  to  his  surprise  he  was  sent  to  this 
institution  March  14,  1885.  He  remained  here  until  October  6,  1886.  The 
patient  states  that  Dr.  Lyons  of  this  institution,  who  at  that  time  was 
First  Assistant  to  Superintendent  Dr.  Godding,  tried  to  poison  him  by 
putting  drugs  into  his  food — some  of  the  drugs  were  croton  oil,  arsenic, 
henbane,  etc.  The  patient  considers  it  all  a  plot  of  Lincoln's  to  keep  the 
money  from  him  and  to  take  it  himself.  According  to  the  patient,  Dr. 
Godding  helped  him  to  get  a  writ  of  habeas  corpus  and  the  patient  was 
discharged  in  the  District  Court  by  Judge  Cox.  The  patient  conducted  the 
case  himself  and  Dr.  Godding  testified  to  his  sanity.  In  1886  he  had  the 
case  brought  up  once  more  before  Judge  Montgomery.  His  lawyer, 
Walker,  would  not  undertake  to  argue  the  case  and  the  patient  thinks 
that  he  also  was  in  conspiracy  against  him.  Judge  Montgomery  took  the 
case  from  the  jury  and  decided  it  himself,  giving  as  his  opinion  that  the 
patient's  claims  were  not  supported  and  deciding  against  the  patient. 

The  patient  again  had  the  case  brought  up  before  the  Senate  and  he  says 
as  a  result,  the  judge  was  removed  from  the  Bench.  The  patient  claims 
that  the  Judge  also  was  bought  off  by  Lincoln,  who  was  then  no  longer 
Secretary  of  War.  The  patient  is  sure  that  Lincoln  got  much  of  the  money 
that  he  himself  was  entitled  to.  He  says  that  he  learned  of  this  from  the 
papers,  that  $250,000  was  missing  from  the  Treasury  Department,  that  this 
was  one  half  of  his  own  money  and  that  it  was  appropriated  by  Lincoln. 
8 


I06  OUTLINES   OF  PSYCHIATRY. 

The  other  $250,000  is  still  in  the  Treasury  for  him.  Mr.  Lincoln  is  now  the 
President  of  the  Pullman  Car  Company.  The  patient  now  desires  to  get 
the  other  $250,000.  He  promised  to  give  Mr.  Harbough  and  Dr.  Glueck 
and  the  examiner  a  goodly  portion  of  what  he  gets.  Patient  says  that 
Cleveland  tried  to  have  him  get  his  money  but  was  held  off  by  friends 
until  the  expiration  of  his  administration;  that  President  McKinley  had 
practically  decided  to  see  that  he  got  his  money  when  he  was  assassinated ; 
that  Roosevelt  had  the  matter  up  and  had  it  all  settled  on  the  eve  of  his 
going  out  of  office  and  that  the  case  was  also  settled  by  Mr.  Taft  but  that 
the  money  is  being  held  up  by  both  the  political  parties.  Patient  says  that 
President  Taft  in  his  inaugural  address  spoke  particularly  of  his  own 
case  and  promised  to  see  that  he  got  the  money.  The  patient  claims  that 
all  the  big  men,  not  only  in  the  United  States  but  in  every  nation,  know 
about  him  and  his  case;  that  it  was  the  cause  of  the  war  with  Spain,  that 
Mr.  Hilles,  who  last  week  resigned  from  ambassadorship  to  Germany,  was 
asked  to  resign  because  he  was  one  of  the  conspirators  in  the  case  and  that 
he  knows  of  several  prominent  men,  including  former  Secretary  of  the 
Treasury  Shaw  and  the  present  Secretary  of  War,  Mr.  Dickinson,  who 
have  their  foot  in  the  plot.  He  claims  that  he  has  been  poisoned  every 
once  in  a  while  for  many  years.  Even  things  that  he  bought  in  the 
different  grocery  stores  contained  some  drug  or  other.  He  says  that  Dr. 
Lyons,  of  New  York,  who  was  interested  in  the  case  on  his  first  admis- 
sion, has  conspirators  in  this  institution  at  the  present  moment.  He  is  not 
sure  whether  or  not  he  is  being  drugged  at  the  present  time.  He  says  he 
would  go  to  work  if  released  but  thinks  he  would  soon  be  sent  for  to 
settle  the  case  with  the  Government.  Patient  says  he  won't  trouble  them 
but  he  will  not  be  out  a  day  before  their  consciences  will  burn  them  so  that 
they  will  come  to  him.  He  will  then  see  that  various  officials  in  this  insti- 
tuion  will  receive  their  just  share  of  the  money  that  he  obtains. 

The  difference  between  this  psychosis  and  the  deHrium  of  inter- 
pretation is  well  shown  in  the  beginning.  It  has  for  its  point  of 
departure  a  fixed  idea,  while  the  delirium  of  interpretation  arrives 
at  a  fixed  idea  only  after  a  prolonged  preliminary  phase.  The 
differential  diagnosis  is  made  difficult  by  several  points  they  pos- 
sess in  common  and  also  by  the  existence  of  combined  psychoses 
or  mixed  types. 

The  symptoms  in  common  of  these  two  forms  are:  the  exag- 
geration of  the  personality,  the  tendency  to  mistrust,  the  per- 
manent lucidity,  the  absence  or  rarity  of  sensorial  disturbances, 
the  absence  of  intellectual  enfeeblement,  and  in  some  cases  the 
apparent  similarity  of  reactions. 

Acute  or  Mild  Paranoia  and  Paranoid  States. — The  question 
whether  the  term  acute  paranoia  is  to  be  retained  is  now  pretty 


PARANOIA   AND   PARANOID   STATES.  lO/ 

well  decided  in  the  negative.  The  existence  of  paranoid  states  in 
some  of  the  acute,  curable  psychoses  has  in  the  past  undoubtedly- 
been  largely  responsible  for  the  persistence  of  Heinroth's  concept 
of  an  acute  form  (Wahnsinn).  Since  the  inner  significance  of 
paranoid  states  has  been  better  understood  and  their  occurrence 
in  many  acute,  curable  psychoses  known,  it  has  been  possible  to 
separate  out  those  trends  belonging  to  other  pyschoses.  When 
this  is  done  a  certain  few  cases  are  found  to  remain  that  may 
properly  be  classed  as  acute,  mild,  or  curable  paranoia. 

These  mild  paranoias^^  develop  as  the  result  of  some  mental 
conflict.  Persistent  mental  perturbation  over  some  condition 
which  can  neither  be  changed  nor  adjusted  to.  Under  these  con- 
ditions a  system  of  delusions  develops,  endogenous  in  origin, 
which  may  or  may  not  be  accompanied  by  ideas  of  reference  and 
which  tends  to  be  pretty  well  confined  to  the  conflict — circum- 
scribed psychosis.  Hallucinations  are  lacking.  After  a  varying 
period  the  affect  subsides,  the  patients  are  able  to  resume  their 
position  in  life  but  the  false  ideas  are  not  corrected.  There  is  re- 
covery without  insight.  Some  of  the  cases  in  severely  tainted  psy- 
chopathic individuals  are  quite  brief ;  many,  however,  last  two  or 
three  years  before  calm  is  secured. 

The  adjective  paranoid  or  paranoiac,  meaning  like  paranoia,  is 
applied  specifically  to  mental  states  showing  more  or  less  sys- 
tematized delusions  of  persecution  and  hallucinations  of  hearing. 
Many  different  mental  disorders  may  present  paranoid  conditions 
and  not  infrequently  paranoid  states  are  met  with  that  are  quite 
difficult  to  definitely  diagnose,  so  that  the  term  is  in  frequent  use. 

These  paranoid  states  are  met  with  in  dementia  precox, 
paresis,  the  toxic  psychoses,  hyperthyroid  and  hypopituitary  states, 
the  psychoses  of  the  involution  period,  manic-depressive  psy- 
chosis, and  in  fact  in  practically  all  of  the  various  types  of  mental 
disease.  In  general  these  states  are  transitory  and  while  present- 
ing the  various  symptoms  of  the  disease  in  which  they  occur  are 
usually  further  characterized  by  a  less  stable  and  coherent  organi- 
zation of  the  delusional  system  which  is  exogenous  in  origin. 
The  paranoid  states  that  occur  in  hypomania  are  particularly  dif- 
ficult to  diagnose,  while  those  which  follow  other  psychoses,  espe- 
cially the  toxic  and  infectious,  as  from  alcohol,  cocaine,  typhoid, 

12  Studies  in  Paranoia,  Nerv.  and  Ment.  Dis.  Monog.  Series,  No.  2. 


I08  OUTLINES    OF    PSYCHIATRY. 

are  particularly  persistent,  often  lasting  for  many  months.    These 
conditions  have  given  origin  to  the  term  secondary  paranoia. 

Interpretation  of  the  Psychosis. 

Freuid's  Conception  of  Paranoia.^^ — In  the  sexual  development 
of  the  individual  a  distinct  homosexual  stage  is  passed  through. 
The  homosexuality,  however,  is  not  left  behind  in  this  process  of 
development  but  the  homosexual  libido  is  sublimated,  that  is,  its 
energies  are  drafted  in  other  channels  such,  for  example,  as  social 
activities.  Freud  believes  that  in  the  paranoiac  there  has  been  a 
fixation  in  this  process  at  one  portion  of  the  homosexual  period  of 
development — the  stage  of  narcissism — and  a  regression  of  the 
sublimated  homosexuality  to  narcissism.  The  libido  of  the  para- 
noiac is  then  projected  upon  those  about  him. 

The  whole  process  is  briefly  and  ingeniously  set  forth  by  Freud 
by  means  of  ringing  the  changes — supposing  the  paranoiac  to  be 
a  male — upon  the  basal  sentence  "  I  love  him,"  thus : 

Delusions  of  persecution  contradict  the  verb.  "  I  love  him " 
is  resented  by  the  individual  who  reacts  to  the  feeling  by  "  I  do 
not  love — I  rather  hate  him."  Then  this  feeling  of  hate  is  pro- 
jected with  the  result  "he  hates  (persecutes)  me,  which  justifies 
my  hating  him."  As  a  result,  this  feeling,  appearing  to  come 
from  an  outer  perception,  becomes  "  I  really  do  not  love  him — I 
hate  him — ^because  he  persecutes  me." 

Erotomania  contradicts  the  object.  "I  do  not  love  him — I  love 
them,"  then  "  I  notice  that  they  love  me,"  then  finally  "  I  do  not 
love  him — I  love  her — because  she  loves  me." 

Delusions  of  jealousy  contradict  the  subject.  "  Not  I  love  the 
man — she  loves  him." 

Delusions  of  grandeur  result  from  a  total  contradiction — a  re- 
jection of  the  whole  sentence.  "  I  do  not  love  at  all,  and  hence  I 
love  nobody."  As  the  libido  must  be  accounted  for  this  is  equiva- 
lent to  "  I  only  love  myself." 

This  mechanism  is  very  important  to  understand  because  of  the 
great  prevalence  of  paranoid  types  of  reaction.  Paranoia,  in  its 
pure  form  as  described  by  Kraepelin  is  a  rare  disorder,  but  para- 

^3  Freud :  Psychoanalytische  Bemerkungen  iiber  einen  autobiographisch 
beschriebenen  Fall  von  Paranoia  (Dementia  paranoides).  Jahrbuch  fiir 
psychoanalytische  und  psychopathologische  Forschungen,  Bd.  Ill,  1911. 


PARANOIA   AND   PARANOID   STATES.  IO9 

noidi  States  are  among  the  most  common  symptoms  of  the  psy- 
choses, either  constituting  the  main  part  of  the  picture  or  being 
incidental  to  more  fundamental  disturbances  (dementia  precox, 
general  paresis)  and,  too,  being  commonly  encountered  among 
the  acceptedly  normal.  The  young  man  who  hears  voices  calling 
him  vile  names  and  accusing  him  of  homosexual  experiences  and 
the  young  woman  who  is  being  followed  and  persecuted  by  men 
are  familiar  pictures  to  every  psychiatrist.  The  explanation  of  a 
breaking  down  of  the  sublimation  of  the  homosexual  libido  is  an 
extremely  illuminating  one.  The  patient  seeks  for  an  attach- 
ment for  his  libido,  the  homosexual  object  does  not  return  his 
feelings  in  kind,  it  is  a  forbidden  object,  he  therefore  only  gets 
pain,  not  satisfaction  and  fulfillment, — and  this  pain  is  felt  as 
coming  from  the  object — projection.  The  fact  that  in  the  delusions 
the  object  is  often  of  the  opposite  sex  does  not  negative  the  ex- 
planation as  the  explanation  already  given  indicates,  it  may  be 
considered  as  a  form  of  disfigurement,  a  disguise  for  the  homo- 
sexual libido  which  is  permitted  to  appear  only  in  the  conven- 
tional heterosexual  trappings. 

Course  and  Prognosis. — The  paranoias  of  Magnan,  Krafft- 
Ebing  and  Kraepelin  and  the  deliria  of  interpretation  and  revin- 
dication, as  described  in  this  chapter,  are  chronic,  irrecoverable 
psychoses. 

The  insanity  of  degenerates  is  not  infrequently  interrupted  in 
its  course  by  intermissions  of  variable  length ;  in  fact,  Magnan 
says  recovery  often  takes  place.  The  mild  forms  recover  in 
variable  periods  without  insight.  Seriously  abnormal  individuals 
having  evident  vices  of  organization,  hereditarily  burdened,  the 
degenerates  of  the  French,  develop  paranoid  conditions  quite 
easily  under  stress  of  circumstances  and  often  as  easily  get  well. 
This  is  well  shown  in  the  paranoid  conditions  that  develop  in 
criminals  during  imprisonment,  the  so-called  prison  psychosis. 

The  delire  chronique  of  Magnan  has  been  classed  by  many 
authors  as  a  form  of  paranoid  dementia  precox.  The  course  and 
prognosis  of  the  paranoid  states  that  occur  in  association  with  the 
different  psychoses  is,  of  course,  the  same  as  that  of  the  psychosis 
of  which  they  are  a  part. 

Differential  Diagnosis. — The  principal  diseases  with  which 
paranoia  is  apt  to  be  confused  are  the  paranoid  forms  of  dementia 


no  OUTLINES   OF  PSYCHIATRY. 

precox.  The  principle  of  differentiation  rests  with  the  occurrence 
in  this  form  of  dementia  precox  of  signs  of  deterioration  foreign 
to  the  classical  type  of  paranoia.  The  deteriorotion,  however, 
may  not  be  very  apparent  in  the  early  stages  and  time  may  be  re- 
quired to  make  the  differentiation. 

Pathology. — Paranoia  has  no  definite  somatic  pathology  as  yet. 
The  hereditary  taint  is  sometimes  manifested  by  errors  of  de- 
velopment— giving  rise  to  malformations  generally  known  as 
stigmata  of  degeneration;  abnormalities  in  the  course  of  the 
cerebral  vessels  and  asymmetries  and  abnormalities  of  gyral  con- 
figuration have  been  noted. 

Treatment. — There  is  no  pharmaceutical  treatment  for  this 
disease.  In  general  it  may  be  said  that  many  of  the  chronic  cases 
require  to  be  cared  for  throughout  their  lives  in  an  institution. 
They  are  peculiarly  unfit  to  live  in  the  outside  world,  and  sooner 
or  later,  as  a  result  of  their  general  conduct  or  some  overt  act,  are 
apt  to  be  committed  as  insane. 

With  the  changes  that  are  coming  about  in  the  general  view- 
points of  psychiatry  even  conditions  which  have  for  long  been 
considered  hopeless  are  being  attacked  therapeutically.  We  are 
just  beginning  to  see  possibilities  in  the  paranoia  situation.  The 
most  notable  success  is  that  reported  by  Bjerre/*  who  success- 
fully treated  a  case  of  ten  years'  duration.  The  psychoanalytic 
approach  to  many  paranoid  conditions  is  quite  successful. 

The  paranoioc  character  differs  in  different  persons  perhaps  as 
much  as  the  average  character.  While  some  paranoiacs  are  dan- 
gerous and  should  be  kept  confined,  others  show  no  dangerous 
tendencies,  are  perhaps  naturally  timid  and  never  would  do  any 
harm,  while  still  others  have  become  resigned  to  their  difficulties. 
While  many  of  this  latter  class  may  often  get  on  for  a  time,  at 
least,  outside  of  an  institution,  they  should  be  kept  under  constant 
observation,  so  that  changes  in  their  delusional  system  and  in 
their  character  of  reaction  can  be  noted.  Psychoanalytic  study  is 
showing  more  clearly  what  constitutes  the  danger  symptoms  in 

i*Jahrbuch  fiir  psychoanalytische  und  psychopathologische  Forschun- 
gen,  VIII,  P'p.  795-847.  For  an  account  of  this  case  in  English,  see  White 
and  Jelliffe,  Modern  Treatment  of  Nervous  and  Mental  Diseases,  Vol.  I, 
Chap.  XIV,  and  Payne:  Some  Freudian  Contributions  to  the  Paranoia 
Problem,  The  Psychoanalytic  Review,  Vol.  II,  No.  i  et  seq. 


PARANOIA  AND   PARANOID  STATES.  Ill 

these  individuals.  A  tendency  to  mysticism  and  highly  evolved 
symbolism  is  the  external  expression  of  an  effort  away  from  anti- 
social conduct. 

In  the  mild  cases  an  effort  should  be  made  to  correct  the  con- 
ditions out  of  which  the  conflict  developed  which  was  the  deter- 
mining factor  in  the  paranoiac  reaction.  This  can  often  best  be 
done  by  an  entire  change  of  surroundings  which,  of  course, 
among  the  poor,  and  those  in  moderate  circumstances,  means  re- 
moval to  an  institution, 

A  better  outlook  for  therapy  in  this  group  has  been  opened  by 
the  psychoanalytic  mode  of  attack  and  psychoanalytic  principles 
will  undoubtedly  enter  largely  into  a  better  type  of  psychotherapy 
for  this  whole  group  of  individuals,  who  in  spite  of  profound 
mental  changes  nevertheless  handle  their  conflicts  better  than 
other  closely  related  reaction  types. 


CHAPTER  IX. 

Manic-Depressive  Psychoses. 

Historical. — In  the  older  psychiatry  a  large  number  of  patients 
were  classified  as  mania  or  as  melancholia.  Practically  all  ex- 
cited and  exalted  patients  were  included  under  the  designation 
of  mania  while  all  the  depressed  patients  were  classed  as  melan- 
cholia. These  two  psychoses  were  generally  conceded  to  be  re- 
coverable, the  percentage  of  recoveries  being  figured  as  high  as 
ninety  by  some.  Then  again  certain  cases  were  recognized  as 
having  a  periodic  tendency  in  which  attacks  of  mania  and  melan- 
cholia followed  one  another  in  regular  succession.  These  patients 
were  conceded  to  be  incurable  and  the  anomalous  circumstance 
was  recognized  of  an  incurable  disease  process  being  constituted 
of  phases  each  one  of  which  consisted,  apparently,  of  an  attack  of 
the  most  curable  form  of  mental  disorder. 

This  concept  continued  until  Kraepelin  came  forward  with  a 
new  synthesis  by  demonstrating  that  "circular  insanity"  mani- 
fested certain  fundamental  symptoms  which  were  characteristic 
of  mania  and  melancholia  and  also  that  mania  and  melancholia 
rarely  occurred  in  isolated  attacks  but,  on  the  contrary,  during 
some  part  of  their  course  exhibited  symptoms  of  the  opposite 
condition — mania  of  melancholia  and  melancholia  of  mania.  This 
analysis  gave  rise  to  the  conception  of  a  single  disease  group  of 
which  mania,  melancholia,  and  circular  insanity  were  simply  dif- 
ferent manifestations  of  one  process  to  which  Kraepelin  gave 
the  name  manic-depressive  psychosis — the  name  indicating  the 
principal  phases  of  its  manifestations. 

Etiology. — The  principal  cause  has  generally  been  supposed  to 
be  hereditary  taint,  and  it  is  noteworthy  that  this  disease  is  often 
found  in  famiHes,  the  constitutional  condition  as  the  basis  on 
which  it  develops  appearing  to  be  directly  transmitted.  Although 
concomitant  conditions  of  stress  are  apparent  with  the  first  and 
even  subsequent  attacks  and  appear  to  condition  them,  still  these 
attacks  are  often  much  more  noticeable  for  their  apparent  lack  of 

112 


MANIC-DEPRESSIVE   PSYCHOSES.  II  3 

cause,  their  spontaneous  onset  thus  evidencing  their  deep-seated 
constitutional  origin.  While  this  is  obviously  true,  a  more  careful 
inquiry  will  very  often  develop  difficult  situations  in  the  patient's 
lives  which  immediately  precede  the  attack  and  which  seem  to 
have  been  the  cause  for  it.  The  causative  relation  is  more  obvious 
in  some  cases  in  which  we  see  practically  the  same  circumstances 
develop  just  before  each  breakdown  such  as  overwork,  family 
quarrels,  etc.  The  real  psychogenic  factors  are  unconscious  and 
therefore  not  apparent  on  the  surface. 

General  Symptomatology. — Before  proceeding  to  a  descrip- 
tion of  the  different  trends  shown  in  the  manic-depressive  psy- 
chosis it  may  be  well  to  pause  for  a  few  moments  and  study  the 
following  diagrams  which  endeavor  to  set  forth  graphically  how 


«    DECFteASCD    PSYCHOMOTOR     ACTIVITY 
=    INCREASED  •'  *• 


=    EMOTIONAL.      EXALTATION 


=  EMOTIONAL      DEPRESSION 


the  various  symptoms  of  the  disease  may  be  combined.  If  note  is 
first  made  of  the  general  way  of  representing  the  opposed  condi- 
tions of  the  psychomotor  and  emotional  states  what  follows  will 
be  perfectly  clear  without  further  explanation. 

The  fact  must  not  be  lost  sight  of  that  the  graphic  method 
here  used  is  only  employed  because  of  its  convenience  in  pictur- 
ing the  several  varieties  of  the  disease.  The  representation  of 
depressed  phases  by  a  curve  below  and  excited  phases  by  a  curve 
above  the  normal  must  not  be  taken  too  literally.  These  condi- 
tions are  strongly  contrasted  only  superficially.  A  deeper  study 
shows  their  fundamental  relationship.  Also  a  change  from  de- 
pression to  exaltation  or  vice  versa  would  seem  to  be  only  possible 
by  passing  through  a  phase,  let  it  be  ever  so  short,  of  the  normal. 
This,  as  a  matter  of  fact,  need  not  occur  at  all.     Bresler^  has 

^  Bresler :  Wesen  und  graphische  Darstellung  des  manischen  Symptomen- 
complexes,  Psych.-Neurol.  Wochenschr.,  Jan.  20,  igo6. 


114 


OUTLINES   OF   PSYCHIATRY. 


BAS£  LINE 
/ 
Z 

3 


•     NORMAL 
e     HYPOMANIA 
«  ACUTE  MANIA 
•  HV  PER  ACUTE  MANIA 


BASE  LINE*  NORMAL 

t  •.  SIMPLE    RETARDATION 
5  'ACUTE    MELANCHOLIA 
J  ^  STUPOROUS   MELANCHOLIA 


RECURRENT     MANIA 


RECURRENT    MELANCHOLIA 


MANIC-DEPRESSIVE   PSYCHOSES. 


115 


emphasized  these  points  and  thinks  the  different  phases  of  the 
disorder  would  be  more  accurately  portrayed  by  representing  both 
conditions  by  curves  below  the  norm — the  manic  phase  being 
shown  by  a  curve  still  lower  than  the  depressive.  More  recent 
studies  would  indicate  that  this  should  be  reversed. 
In  describing  this  disease  the  two  principal  stages — the  manic 


CiRcuLA/^    I NQ AN  try 


ALTERNATING     /NQANITY 

and  the  depressive — will  be  described  first,  then  the  various  forms 
of  periodic  insanity,  and  finally  certain  irregular  and  unusual 
combinations  of  symptoms  known  as  the  mixed  states  will  receive 
attention. 

Manic  Phase. 

This  stage  of  manic-depressive  psychosis  manifests  itself  by 
three  cardinal  symptoms,  viz.,  (i)  Flight  of  ideas.  (2)  Psycho- 
motor excitement.    (3)  Emotional  excitement.    These  symptoms 


ALTenNATlNG    /NSAhHTY  OF   DOUBLE   PHASE 

may  manifest  themselves  in  any  degree  of  severity  and  the  con- 
tent of  consciousness  may  vary  in  different  cases.  For  purposes 
of  description  it  is  convenient  to  divide  mania  into  three  grades  in 


Il6  OUTLINES   OF   PSYCHIATRY. 

accordance  with  its  severity.  These  grades  also  answer  very  well 
to  the  clinical  types  met  with  although  it  must  of  course  be  under- 
stood that  the  mania  may  be  of  any  degree  of  severity  and  that  in 


/AjsANiry  or  double  form 


MANiACfyL     STUPOH 


AGITATED      DEPRESSION 


MIXED      STATES     OCCURRING     eiQPEC/ALLY    AT 

THE  TRAAJS/T/O/V  FROM  ONE  STAGE  TO  ANOTHEfi 

a  given  case  it  may  manifest  itself  in  dififerent  degrees  at  different 
times  during  the  same  attack. 

It  must  not  be  forgotten,  too,  that  these  three  cardinal  symp- 
toms may  not  be  all  of  the  same  degree  of  severity.  For  example 
the  flight  of  ideas  may  be  extreme,  out  of  all  proportion  to  the 
amount  of  psychomotor  activity  which  may  only  show  slight 
increase. 


MANIC-DEPRESSIVE   PSYCHOSES.  II 7 

Hypomanm  is  the  term  applied  to  the  mildest  of  these  degrees 
of  maniacal  excitement.  Here  in  the  simpler  cases  there  is  a  dis- 
order of  the  process  of  thinking  rather  than  a  disturbance  in  the 
content  of  thought.  The  separate  ideas  and  even  acts  may  not  be 
unusual  and  yet  when  taken  in  their  ensemble  are  seen  to  be  dis- 
tinctly abnormal.  The  example  given  by  Mercier^  illustrates  this 
very  well.  He  says  of  a  case  of  this  sort,  "  Its  subject  rises  early, 
full  of  schemes  of  business  or  pleasure.  He  fusses  noisily  about 
the  house,  indifferent  to  his  disturbance  of  other  people's  slumbers. 
He  is  very  impatient  of  delay,  he  cannot  wait  a  minute  for  any- 
thing that  he  wants,  and  if  it  is  not  forthcoming  on  the  instant, 
he  flies  into  a  rage.  The  course  of  the  post  is  not  expeditious 
enough  for  him.  He  sends  his  letters  by  telegraph,  and  his  letters 
are  extraordinarily  numerous.  They  would  be  numerous  in  any 
case,  but  their  number  is  doubled,  and  more  than  doubled,  by 
the  frequent  changes  of  his  mind,  and  by  the  impulsiveness  with 
which  he  acts  upon  every  passing  whim.  He  determines  to  make 
some  purchase,  probably  a  very  unnecessary  one,  but  one  for 
which  he  can  adduce  twenty  plausible  reasons,  and  he  writes  to 
tell  his  solicitor  that  he  will  call  the  next  morning.  Scarcely  is 
the  letter  posted  when  he  sees  that  he  will  attain  his  object  more 
quickly  by  asking  his  solicitor  to  lunch.  He  telegraphs  accord- 
ingly. Before  his  messenger  returns,  it  occurs  to  him  that  he 
had  better  ask  the  vendor  to  lunch  also.  Another  telegram  is 
dispatched,  and  since  he  cannot  entertain  more  than  one  visitor 
at  his  club,  another  must  be  sent  to  the  solicitor  to  announce  the 
change  to  a  hotel.  Then  he  remembers  that  he  has  been  draw- 
ing heavily  of  late  on  his  banking  account,  and  that  he  may  not 
have  the  necessary  funds  available.  Another  telegram  to  the 
bank.  But  if  there  are  insufficient  funds  in  the  bank,  he  will 
have  to  sell  stock  to  raise  the  funds;  another  telegram  to  his 
broker.  Then  he  determines  that  it  will  be  better  to  pledge  the 
stock  to  the  bank  rather  than  to  sell  it.  More  telegrams  to  the 
broker  and  to  the  bank.  The  broker  won't  like  the  contradictory 
orders — never  mind;  ask  him  to  dinner — ask  them  all  to  dinner. 
Put  off  the  lunch  and  have  a  dinner  instead,  and  ask  the  solicitor, 
the  vendor,  the  banker  and  the  broker.  Yes,  and  why  not  Smith 
and  Jones  and  Robinson  as  well?     More  telegrams;  and  then, 

2  Charles  Mercier :  A  Text-Book  of  Insanity.     London  and  New  York, 
1902. 


Il8  OUTLINES   OF   PSYCHIATRY. 

since  two  out  of  the  three  of  the  invited  guests  decline,  the  whole 

thing  is  postponed,  also  by  telegraph.  Meantime,  in  the  intervals 
of  telegraphing,  his  hands  have  been  full.  He  has  been  con- 
stantly ringing  the  bell  and  giving  orders — ^giving  them,  modifying 
them,  and  countermanding  them — constantly  wanting  something 
fresh,  running  up  and  down  stairs,  writing  letters,  haranguing 
this  person  and  that,  flying  into  a  rage  upon  the  slightest  oppo- 
sition, tearing  the  bell  down  on  the  slightest  delay,  and  talking 
almost  incessantly." 

In  this  example  the  subject's  acts  might  almost  all  of  them 
be  considered  as  normal  with  the  exception  of  those  due  to  imdue 
irritability  or  anger.  Aside  from  these  each  act  is  consistently 
directed  to  some  definite  aim.  The  disorder  is  not  in  the  con- 
tent of  thought  but  in  the  process  of  thinking  and  the  disorder 
of  process  manifests  itself  by  a  rapid,  too  frequent  change  of 
direction. 

In  this  condition  the  patient  is  constantly  active,  busying 
himself  about  one  thing  and  another,  talking  continuously  mean- 
while, often  in  a  loud  and  rather  boisterous  manner,  while  emo- 
tionally, exaltation  is  manifested  by  good  humor,  a  smiling  coun- 
tenance and  increased  self-esteem,  punctuated  m.ayhap  by  attacks 
of  irritability  or  impulsive  anger  with  little  or  no  cause.  His 
confidence  in  his  own  ability  is  unqualified  and  is  shown  in  the 
outlining  of  all  manner  of  schemes  of  work,  investments,  busi- 
ness enterprises  and  the  like.  Flight  of  ideas  is  marked  though 
not  of  high  degree,  the  conversation  changing  at  frequent  inter- 
vals from  subject  to  subject  and  the  activities  show  a  like  charac- 
teristic, there  being  no  consistent  effort  directed  toward  any  one 
aim  for  any  length  of  time.  Letters  are  often  written  in  great 
numbers  and  their  contents  exhibit  the  same  characteristics  as 
do  the  speech  and  conduct.  The  patient  is  fully  oriented,  there 
is  no  clouding  of  consciousness  nor  delusions.  In  spite,  however, 
of  the  lucidity  and  apparent  abundance  of  energy  the  real  efficiency 
of  the  individual  is  greatly  reduced  largely  because  of  the  lack  of 
consecutiveness  in  application.  Ofttimes  the  picture  is  compli- 
cated by  the  addition  of  symptoms  due  to  alcoholic  indulgence 
which  is  very  common  in  patients  in  this  condition,  many  of  whom 
show  marked  moral  delinquencies  and  because  of  their  lucidity 
and  facility  of  expression  often  elude  the  authorities,  being  at  once 


MANIC-DEPRESSIVE   PSYCHOSES.  II 9 

discharged  after  examination  when  apprehended  because  of  sup- 
posed insanity. 

The  next  grade  of  maniacal  excitement  presents  perhaps  the 
most  characteristic  picture  of  this  stage  and  is  the  classical  con- 
dition of  acute  mania. 

In  this  condition  the  flight  of  ideas  is  well  marked  even  to  the 
point  oftentimes  that  the  train  of  thought  is  apparently  quite 
incoherent.  Distractibility  is  a  prominent  feature  and  the  almost 
constant  flow  of  ideas  frequently  refers  to  something  seen  or 
heard  in  the  environment.  A  tendency  to  rhyme  is  not  infre- 
quently present  and  words  heard  by  the  patient  are  often  woven 
into  or  form  the  starting  point  for  these  rhymes  which  may  be 
nothing  more  than  a  string  of  words  of  similar  sound  (clang 
association).  It  is  quite  remarkable  how  such  a  patient  who  is 
apparently  paying  no  heed  to  what  is  going  on  about  him  will 
catch  a  chance  word  or  phrase  uttered  by  some  one,  perhaps  a 
considerable  distance  away,  and  introduce  it  into  the  stream  of  his 
conversation. 

Consciousness  may  be  more  or  less  clouded  and  there  is  often 
some  disorientation;  this  is  especially  noticeable  for  persons. 
This  condition,  however,  is  largely  if  not  wholly  due  to  the  dis- 
order of  attention.  The  patient  does  not  adequately  perceive  the 
environment,  therefore  a  comprehensive  idea  of  it  is  not  obtained 
and  in  the  rapid  and  transitory  survey  a  superficial  quality  is  often 
emphasized — ^perhaps  some  resemblance — and  the  person  or  object 
is  mistaken.  In  this  way  the  nurses  and  physicians  are  called 
by  the  names  of  friends  or  relatives  and  the  surroundings  are 
said  to  be  those  of  some  place  the  patient  has  been  in  the  past. 
These  errors  are,  however,  often  not  firmly  fixed  and  the  patient 
may  correct  them  spontaneously  at  times. 

The  disorders  of  attention,  flight,  distractibility  are  all  elements 
in  producing  a  content  of  consciousness  in  which  all  ideas  have 
the  same  value.  Nothing  is  attended  to  long  enough  to  give  it 
an  importance  greater  than  other  experiences,  ideas  are  voiced 
first  about  this  subject  and  then  about  that,  the  patient  changing 
from  subject  to  subject  without  attaching  more  importance  to 
one  than  to  another,  without  being  led  by  one  idea  to  the  exclusion 
of  others — there  is  a  leveling  of  ideas — all  ideas  reach  the  same 
level  of  importance  in  consciousness. 


I20  OUTLINES   OF   PSYCHIATRY. 

Hallucinations  are  not  infrequent.  They  are  usually  element- 
ary in  character,  simple  and  transitory. 

Delusions  may  also  be  present  but  are  not  fixed  but  changeable, 
coming  and  going.  They  are  usually  of  a  grandiose  character, 
but  lack  the  element  of  extreme  improbability  or  absolute  ridicu- 
lousness often  seen  in  conditions  of  deterioration.  Occasionally  a 
paranoid  state  develops  with  quite  stable  delusions  of  persecution. 
This  condition  is  difficult  to  diagnose  especially  if  the  excitement 
is  of  a  mild  character  as  in  hypomania. 

The  psychomotor  activity  is  constant.  There  seems  to  be  abso- 
lute inability  to  keep  quiet — pressure  of  activity — the  patient  runs 
and  jumps,  turns  somersaults,  waves  the  arms  about,  tears  up 
his  clothing,  destroys  plants,  breaks  furniture,  howls  and  yells 
all  night  long,  going  almost  absolutely  without  sleep,  often  show- 
ing marked  sexual  excitement.  The  excitement  is  so  great  that 
these  patients  do  not  even  take  time  to  eat,  food  placed  before 
them  is  perhaps  tasted  and  then  thrown  about  like  everything  else 
that  comes  in  their  way,  so  that  emaciation  soon  becomes  marked. 
In  less  marked  degrees  of  excitement,  however,  it  is  common  for 
this  class  of  patients  to  gain  in  weight. 

The  emotional  exaltation  is  marked  and  shown  by  boisterous 
laughter  and  remarks  showing  exaggerated  ideas  of  self-esteem 
and  personal  prowess.  The  patients  are  apt  to  be  very  irritable 
in  this  condition  and  are  constantly  fomenting  trouble  of  some 
sort  on  the  wards  where  they  are  confined. 

The  third  grade  of  maniacal  excitement  is  merely  a  more  aggra- 
vated form  of  the  condition  just  described  and  may  be  called 
delirious  mania. 

In  this  condition  the  flight  is  so  great  as  to  amount  to  almost 
complete  incoherence,  the  activity  is  unremiting,  cansciousness  is 
more  clouded  and  hallucinations  are  more  in  evidence.  The  con- 
dition leads  to  great  exhaustion  and  physical  depletion,  and  it  fre- 
quently happens  that,  as  a  result  of  slight  scratches  and  bruises 
obtained  during  the  period  of  great  motor  restlessness,  and  which 
are  not  allowed  to  be  properly  dressed,  local  areas  of  suppuration 
develop,  so  that  a  mild  septicemia  with  some  temperature  compli- 
cates the  picture.  Exhaustion  and  toxemia  are  both  now  added, 
the  clouding  of  consciousness  becomes  profound,  a  true  delirium 
takes  the  place  of  the  flight,  marked  by  absolute  incoherence  and 


MANIC-DEPRESSIVE   PSYCHOSES.  121 

complete  confusion  {secondary  confusion)  with  transitory  and 
elementary  sensory  falsifications. 

The  acxite  dilirious  mania,  which  used  to  be  described  as  always 
and  invariably  fatal,  was  probably  in  a  certain  proportion  of  cases 
an  aggravated  form  of  the  manic  stage  of  manic-depressive  psy- 
chosis. It  is  probable,  however,  that  it  was  more  usually  an  acute 
psychosis  associated  with  some  serious,  though  often  unrecog- 
nized, condition  of  the  internal  organs,  as  i.  e.,  an  acute  nephritis 
or  pneumonia.  It  can  be  readily  seen  how  such  conditions  might 
be  overlooked  in  patients  so  wildly  excited  and  autopsies  of  late 
have  tended  to  show  that  this  was  the  case. 

A  very  few  cases,  usually  late  in  the  history  of  the  disease,  do 
not  recover  in  the  usual  length  of  time  from  their  maniacal  period. 
They  pass  into  a  condition  of  chronic  excitement — chronic  mania 
— which  may  in  exceptional  cases  last  several  years.  The  exact 
nature  of  these  cases  is  not  understood. 

Depressive  Phase. 

This  stage  of  the  manic-depressive  psychosis  also  manifests  it- 
self by  three  cardinal  symptoms,  each  one  of  which  is  opposed  to 
the  corresponding  symptom  of  the  manic  stage,  viz.,  i.  Difficulty  of 
thinking.    2.  Psychomotor  retardation.     3.  Emotional  depression. 

This  set  of  symptoms  may,  as  in  the  manic  set,  manifest  itself 
with  any  degree  of  severity  and  the  three  symptoms  may  not  all 
vary  proportionately.  The  retardation,  for  example,  may  be  quite 
out  of  all  proportion  to  the  depression. 

As  with  the  manic  phase  it  is  convenient  to  consider  the  de- 
pressive phase  in  three  different  grades. 

The  mildest  grade  of  depression  is  called  simple  retardation. 
The  word  retardation  here,  as  frequently,  refers  not  only  to  psy- 
chomotor retardation  but  to  the  difficulty  in  thinking,  as  the  two 
phenomena  are  in  reality  similar  manifestations  in  different 
spheres.  This  designation — simple  retardation — is  significant, 
too,  because  the  emotional  state  is  not  indicated  and  as  a  matter 
of  fact  is  of  less  importance  diagnostically  than  the  retardation. 

These  patients  move  slowly,  speak  slowly  and  in  a  low  tone, 
often  only  just  above  a  whisper,  and  by  preference  answer  ques- 
tions in  monosyllables.  They  sit  about  with  folded  hands  doing 
nothing;  they  are  incapable  of  effort  of  any  sort,  even  reading  is 


122  OUTLINES    OF    PSYCHIATRY. 

not  indulged  in,  for,  aside  from  the  effort  required,  what  is  read 
is  not  assimilated,  ideas  are  not  called  up  by  what  is  read,  and 
the  continuous  effort  is  impossible. 

Emotionally  the  patient  is  depressed  but  the  depression  may 
not  be  at  all  marked  and  in  these  cases  the  facial  expression  may 
fail  to  indicate  it  at  all.  They  often  realize  their  mental  inva- 
lidism and  are  distressed  by  it.  Consciousness  is  not  clouded  and 
they  are  fully  oriented. 

The  next  grade  of  depression  is  the  ordinary  acute  melancholia. 
In  this  condition  the  three  cardinal  symptoms  of  depression  are 
manifested  in  a  much  more  pronounced  way.  The  patients  are 
inactive,  sitting  by  themselves,  showing  little  or  no  tendency  to 
associate  with  others,  their  movements  are  very  slow  and  delib- 
erate, and  it  often  takes  a  considerable  time  to  initiate  them 
(initial  retardation).  The  speech  is  similarly  affected;  it  is  slow, 
preferably  monosyllabic,  and  often  almost  inaudible.  Initial  re- 
tardation is  very  noticeable  here  also.  The  emotional  depression 
is  profound  and  is  indicated  in  the  attitude  which  is  in  general 
one  of  flexion,  the  hands  lie  limp  in  the  lap,  the  head  is  inclined 
forward  so  that  the  chin  rests  on  the  breast,  the  shoulders  are 
also  bent  forward  and  the  whole  attitude,  together  with  the  facial 
expression,  indicates  sadness. 

In  this  condition  delusions  are  the  rule  and  are  typically  self- 
accusatory.  The  patients  think  themselvs  responsible  for  all  the 
sin  and  wickedness  or  privation  and  suffering  in  the  world ;  they 
are  the  cause  of  the  unfortunate  condition  of  their  fellow  patients, 
have  themselves  committed  some  great  sin,  and  are  forever  and 
absolutely  lost.  They  very  often,  too,  have  hypochondriacal  ideas, 
think  they  have  some  incurable  disease,  that  their  organs  are  de- 
cayed, something  has  happened  to  their  brain,  their  bowels  are 
stopped  up  and  the  like. 

The  changes  in  the  organic  sensations  produce  peculiar  feel- 
ings which  are  variously  interpreted,  often  leading  to  more  or 
less  disaggregation  of  the  personality,  the  strange  feelings  being 
supposed  to  indicate  mysterious  changes  going  on  within  the  body. 
A  patient  will  keep  going  to  the  looking-glass  to  look  at  her  eyes, 
averring  that  they  look  like  cat's  eyes,  that  they  are  cat's  eyes. 
It  is  only  a  step  from  this  condition  to  a  belief  in  the  complete 


MANIC-DEPRESSIVE    PSYCHOSES.  I  23 

transformation  of  the  personality  or  a  belief  that  another  being 
has  taken  possession  of  their  body  and  expresses  itself  in  their  acts. 

Hallucinations  also  occur,  but  consciousness  is  usually  quite 
clear  and  the  patient  may  be  fully  oriented.  However,  a  marked 
degree  of  clouding  is  not  uncommon  and  hallucinations  and  delu- 
sions may  be  the  outcome  of  insufficient  perception  of  the  environ- 
ment, as  in  the  instance  previously  cited  of  the  patient,  who, 
profoundly  depressed,  was  so  wrapped  up  in  her  sufferings  that 
she  did  not  perceive  the  nurse  bring  the  tray  of  food  and  set  it 
beside  her  and  when  her  attention  was  called  to  it  thought  it  must 
have  been  placed  there  by  some  mysterious  agency. 

Physically  there  is  almost  invariably  present  constipation,  coated 
tongue,  indicanuria,  poor  appetite,  loss  of  weight,  with  disturbed 
sleep  and  poor  circulation,  with  cold  and  often  blue  extremities. 

The  third  and  most  marked  grade  of  depression  is  depressive 
stupor.  In  this  condition  the  retardation  has  proceeded  to  such 
an  extent  that  the  patient  does  not  speak.  He  lies  in  bed,  often 
for  days  at  a  time,  in  this  almost  absolutely  inactive  state,  having 
to  be  fed  and  his  every  want  ministered  to. 

During  this  condition  of  great  retardation  the  patient  may  be 
suffering  from  the  most  dreadful  delusions  and  hallucinations. 
This  condition  of  mind  may  be  shown  by  an  anxious  expression 
of  countenance,  but  its  details  can  only  be  learned  after  the  patient 
recovers  sufificeintly  to  describe  them.  The  hallucinations  present 
themselves  to  the  patient  as  in  a  dream  and  there  is  a  considerable 
degree  of  clouding  of  consciousness  present,  to  some  extent  due 
to  the  absorption  of  the  patient's  attention  by  these  hallucinations. 

This  condition  of  stupor  is  common  in  the  course  of  melancholia 
and  occurs  as  an  episode  more  often  than  as  a  distinct  form  of 
the  disease. 

The  Periodical  Psychoses. 

Under  this  head  are  included  those  forms  which  have  been 
severally  described  as  recurrent  mania,  periodic  mania,  intermit- 
ten  mania,  recurrent  melancholia,  insanity  of  double  form,  alter- 
nating insanity,  etc. 

All  of  these  mental  disturbances  are  merely  different  manifesta- 
tions of  a  manic-depressive  psychosis,  the  manic  and  depressive 
stages  being  represented  in  various  relations,  often  separated  by  a 


124  OUTLINES   OF  PSYCHIATRY. 

quiescent  period.  Thus  recurrent  mania  would  consist  of  recur- 
rent attacks  of  a  manic  phase  separated  by  quiescent  periods, 
similarly  for  recurrent  melancholia,  while  the  alternating  type 
would  consist  of  manic  and  depressive  attacks,  each  followed  by 
a  quiescent  period ;  circular  types,  on  the  other  hand,  being  cycles 
of  manic  and  depressive  stages  without  intervals  of  separation, 
while  a  manic-depressive  psychosis  of  double  form  would  consist 
of  cycles  of  excitation  and  depression,  each  cycle  followed  by  a 
quiescent  period.  Other  varieties  might  be  described,  but  it 
suffices  to  say  that  the  three  stages — ^manic,  depressive  and 
quiescent  periods — may  be  combined  in  any  possible  way,  and 
that  further  in  a  given  case  any  degree  of  the  manic  or  depressive 
stages  may  occur. 

The  following  is  an  account  by  an  intelligent  woman  of  her  feel- 
ings in  both  periods  of  excitement  and  depression: 

"  I  have  suffered  all  my  life  from  excitements  and  depressions,  although 
it  was  not  until  I  was  fifty-eight  years  of  age  that  my  family  and  I 
realized  that  I  was  really  insane  and  required  institutional  care.  During 
youth  and  middle  age  my  excitements  were  of  a  mild  character,  and  during 
these  periods  I  considered  myself  normal.  I  felt  peculiarly  happy  and 
care  free.  I  managed  my  household  affairs  with  the  greatest  ease.  I 
entertained  and  mingled  in  society  with  pleasure  and  zest.  I  was  lively, 
talkative  and  I  have  reason  to  believe  I  was  witty  and  entertaining.  I 
could  work  without  an  effort.  I  at  times  accomplished  almost  Herculean 
tasks.  On  one  occasion  I  remember  preparing  and  conducting  a  church 
entertainment  by  which  the  sum  of  $8oo.cx3  was  raised.  Of  late  years  my 
excitements  have  grown  more  severe.  I  begin  iby  taking  an  overactive 
interest  in  everything  going  on  around  me.  Everything  seems  rosy.  I  feel 
happy  and  nothing  depresses  me.  I  feel  propelled  by  some  unknown  force 
to  constant  action.  I  am  possessed  with  the  idea  of  righting  wrongs  and 
.straightening  out  things  in  general.  All  the  faults  in  the  administration  of 
the  ward,  the  Hospital  and  the  Government  must  be  corrected. 

********* 

"  My  excitements  have  never  led  me  to  commit  any  acts  of  violence.  I 
occupy  myself  largely  in  talking  and  writing  letters.  My  room  is  often  in 
disorder  because  I  cannot  stay  at  one  job  long  enough  to  complete  it. 
As  I  feel  these  excitements  approaching,  I  request  the  physician  in  charge 
of  me  to  take  up  my  parole,  as  I  know  I  shall  be  moved  to  do  and  say 
many  foolish  things  of  which  I  will  be  ashamed  later.  No  one  who  has 
not  had  experience  can  realize  the  mortification  of  having  been  insane. 

"  My  depressions  in  early  life  were  as  mild  as  my  excitements,  the  onset 
was  gradual.  I  felt  a  disinclination  to  mingle  in  society.  When  forced  to 
do  so  I  sat  like  a  "  dummy  "  and  could  think  of  nothing  to  say.    My  house- 


MANIC-DEPRESSIVE   PSYCHOSES.  125 

hold  duties  became  a  burden.  One  after  another  of  these  was  dropped 
until  the  care  of  the  household  was  entirely  given  over  to  relatives  or 
servants.  I  learned  from  experience  a  treatment  of  my  own.  As  soon  as 
I  felt  a  depression  approaching,  I  promptly  dropped  everything  and  left 
home  for  a  time.  I  found  by  getting  away  from  family  cares  and  respon- 
sibilities, and  from  the  demands  of  society,  to  some  quiet  spot,  I  could 
shorten  the  duration  of  these  depressions.  In  recent  years  the  depressions 
have  appeared  suddenly.  One  day  I  went  to  town  to  do  some  shopping 
for  a  friend.  I  went  to  a  grocery  store  to  make  some  purchases.  It  sud- 
denly occurred  to  me  that  I  could  make  these  to  much  better  advantage  at 
the  market  only  a  block  away.  Suddenly  I  realized  that  I  did  not  have 
sufficient  energy  to  go  to  the  market,  and  that  another  depression  was  upon 
me.  It  was  with  the  greatest  difficulty  that  I  ordered  the  goods,  paid  for 
them  and  came  home.  At  these  times  my  brain  feels  paralyzed.  I  have  not 
the  strength  or  ambition  to  do  anything.  I  am  apprehensive  lest  some 
harm  has  befallen  the  members  of  my  family,  but  to  save  my  life,  I  could 
not  write  or  telephone  to  find  out  if  my  fears  are  true.  I  have  the  impulse 
to  act,  but  it  seems  as  if  something  shuts  down  and  prohibits  action.  I 
see  my  clothes  becoming  soiled — I  know  I  should  change  them,  but  I  cannot 
pull  out  the  drawer  of  my  bureau  and  get  clean  ones.  This  inertia  is 
greater  in  the  morning  than  at  night.  Before  I  came  to  the  Government 
Hospital  I  had  servants  who  slept  at  home,  and  came  to  my  house  early  in 
the  morning.  When  my  husband  was  away  and  my  children  were  small, 
it  devolved  upon  me  to  admit  these  servants  early  in  the  morning.  I 
knew  that  when  morning  came  to  dress  and  go  down  stairs  would  be 
impossible.  I  solved  the  difficulty  by  dressing  the  night  before  and  sleep- 
ing in  my  clothes.  When  the  depression  is  most  profound,  I  move  in  a 
fixed  groove.  I  never  vary  a  hair's  breadth.  At  first  I  have  a  desire  to 
remain  in  bed.  Once  this  is  overcome  I  have  no  choice  but  to  remain  up. 
I  sit  in  the  same  seat  and  in  the  same  attitude  for  weeks.  As  I  come  down 
stairs  in  the  morning  I  am  apprehensive  lest  my  seat  be  taken,  and  I 
wonder  what  I  shall  do  if  it  should  be  occupied,  although  the  sitting  room 
is  well  supplied  with  comfortable  seats.  I  bring  a  shawl  with  me,  and 
place  it  in  the  chair  so  that  no  one  will  appropriate  it  while  I  am  at 
breakfast. 

"  After  each  depression,  I  suffer  from  intense  pain  in  my  back,  side, 
shoulders  and  arms.  This  is  dull  and  aching  in  character,  and  remains 
with  me  for  weeks  after  the  depression  has  disappeared.  After  the  last 
depression  I  suffered  from  a  severe  attack  of  the  shingles.  The  skin  erup- 
tion has  now  disappeared,  but  the  pain  still  remains." 

The  mild  grade  of  the  manic-depressive  psychosis,  those  cases 
in  which  it  would  be  well  nigh  impossible  to  make  a  diagnosis 
from  seeing  a  single  attack,  is  sometimes  called  cyclothymia. 
Here  one  must  get  the  history  over  a  sufficiently  long  period  to 


126  OUTLINES    OF   PSYCHIATRY. 

show  the  periodic  changes  of  character  in  order  to  appreciate  the 
nature  of  the  trouble. 

These  cases  are  of  great  clinical  importance  because  quite  char- 
acteristically associated  with  visceral  disturbances.  In  the  mild 
depressions  symptoms  will  be  complained  of  which  refer  to  the 
gastro-intestinal  or  the  genito-urinary  systems.  The  true  nature 
of  the  case  is  usually  not  recognized  and  their  spontaneous  re- 
covery referred  to  the  treatment.  Many  of  the  so-called  dipso- 
manias are  dependent  upon  recurrent  manic-depressive  episodes. 

The  Mixed  States. 

The  mixed  staes  are  forms  of  manic-depressive  psychosis  in 
which  the  three  cardinal  symptoms  of  the  manic  and  depressive 
stages  are  mixed  so  that  the  resulting  state  is  neither  one.  The 
best  recognized  are:  (i)  Maniacal  Stupor,  (2)  Agitated  Depres- 
sion, (3)  Unproductive  Mania,  (4)  Depressive  Mania,  (5)  De- 
pression with  Flight  of  Ideas,  (6)  Akinetic  Mania.  It  will  suffice 
to  merely  mention  the  symptoms  of  these  groups. 

Maniacal  Stupor. — Emotional  exaltaion,  decreased  psychomo- 
tor activity,  difficulty  of  thinking. 

Agitated  Depression. — Emotional  depression,  increased  psycho- 
motor activity,  flight  of  ideas. 

Unproductive  Mania. — Emotional  exaltation,  increased  psycho- 
motor activity,  difficulty  of  thinking. 

Depressive  Mania. — Emotional  depression,  difficulty  of  think- 
ing, increased  psychomotor  activity. 

Depression  with  Flight  of  Ideas. — Emotional  depression,  flight 
of  ideas,  decreased  psychomotor  activity. 

Akinetic  Mania. — Emotional  exaltation,  flight  of  ideas,  de- 
creased psychomotor  activity. 

Still  the  possibilities  are  not  exhausted.  It  is  quite  uncommon 
to  see  any  one  of  the  conditions  already  described  continue  pure 
from  the  commencement  to  the  end  of  the  attack.  In  the  manic 
stage  symptoms  of  depression  not  infrequently  crop  up  and 
occupy  the  field  temporarily,  while  during  the  depressive  stage  it 
is  quite  as  common  to  note  transitory  periods  of  excitement. 
Then  it  is  quite  common  for  manic  attacks  to  be  preceded  by  a 
longer  or  shorter  attack  of  depression,  and  sometimes  such  a 
period  of  depression  follows,  not  infrequently  but  partial  depres- 


MANIC-DEPRESSIVE    PSYCHOSES.  12/ 

sion  of  the  type  of  unproductive  mania.  The  depressive  stage 
shows  similar  variations,  more  particularly  is  it  followed  by  a 
short  period  of  exaltation.  Then,  again,  at  any  stage  of  the  dis- 
ease a  mixed  state  may  crop  up  for  a  time,  so  that  during  the 
course  of  the  manic  stage  psychomotor  retardation  may  occur  or 
during  the  stage  of  depression  emotional  exaltation  may  develop, 
while  in  the  various  forms  of  the  periodic  psychoses  it  is  quite 
the  rule  to  find  these  mixed  states  at  the  transition  places  from 
one  stage  to  another,  all  of  the  symptoms  of  one  stage  not  equally 
and  contemporaneously  graduating  into  the  opposites.  Thus 
during  the  course  of  a  circular  insanity  the  aflfect  may  change 
from  depression  to  exaltation  before  the  psychomotor  retardation 
has  given  place  to  increased  psychomotor  activity,  thus  producing 
a  temporary  mixed  state. 

Interpretation  of  the  Psychosis. 

Manic-depressive  psychosis  is  the  type  of  extroversion  reac- 
tion. That  is,  the  patients  instead  of  turning  within  themselves 
(introversion)  try  to  escape  their  difficulties  (conflict)  by  a  "flight 
into  reality."  This  flight  into  reality  is  the  manic  phase  of  the 
psychosis  with  its  flight  of  ideas,  distractibility  and  increased 
psychomotor  activity  during  which  the  patient  seems  to  be  at  the 
mercy  almost  of  his  environment  having  his  attention  diverted  by 
every  passing  stimulus.  The  great  activity  can  be  understood  as 
a  defense  mechanism.  The  patient  appears,  by  his  constant  ac- 
tivity to  be  covering  every  possible  avenue  of  approach  which 
might  by  any  possibility  touch  his  sore  point  (complex)  and  so  he 
rushes  wildly  from  this  possible  source  of  danger  to  that  mean- 
while keeping  up  a  stream  of  diverting  activities.  He  is  at  once 
running  away  from  his  conflict — into  reality — and  trying  to  ade- 
quately defend  every  possible  approach. 

The  manic-depressive  psychosis  is  seen  therefore  not  to  be  char- 
acterized so  much  by  the  nature  of  the  difficulty  (conflict)  with 
which  the  patient  has  to  deal  as  by  the  way  in  which  he  deals  with 
it.  This  method  I  have  described  as  a  "  flight  into  reality  "  which 
is  the  characteristic  of  the  manic  phase,  while  the  failure  to  deal 
adequately  with  the  difficulty  is  manifested  by  the  depression  of 
the  depressive  phase.  In  the  depression  the  defenses  have  broken 
down  and  the  patient  is  overwhelmed  by  a  sense  of  his  moral 


128  OUTLINES   OF   PSYCHIATRY. 

turpitude  (self-accusatory  delusions).  This  sense  of  being  sinful 
is  the  conscious  appreciation  of  tendencies  which  should  have  been 
left  behind  to  become  a  part  of  the  historical  past  (the  uncon- 
scious) in  the  course  of  the  development  of  the  psyche  but  which 
still  demand  expression.  Sexual  curiosity  which  is  all  right  for 
the  naive  child  and  belongs  to  the  childhood  period  of  develop- 
ment becomes  morally  wrong  in  the  adult  who  wishes  to  satisfy 
it  by  a  "  Peeping-Tom  "  sort  of  activity.  Such  infantile  activi- 
ties are  thus  felt  as  morally  wrong  and  explain  why  the  patients 
with  such  tendencies  feel  themselves  to  be  wicked. 

The  benign  character  of  the  manic-depressive  group  of  psy- 
choses is  explained  because  of  their  extroverted  mechanism. 
Reality  is  the  normal  direction  for  the  libido  and  because  the 
direction  is  normal  they  more  readily  result  in  recovery. 

Inasmuch  as  we  are  dealing  in  this  group  only  with  a  special 
form  of  mechanism  it  is  well  to  voice  a  word  of  caution  about 
considering  manic-depressive  psychosis  as  a  cut  and  dried  disease 
concept.  It  is  not — it  represents  only  a  special  way  of  reacting 
and  therefore  we  may  and  actually  do  find  the  manic-depressive 
type  of  reaction  not  only  among  normal  persons  but  in  association 
with  other  disease  types — paresis. 

Even  in  dementia  precox  the  mechanisms  of  which  are  dia- 
metrically opposed  (introversion)  we  may  see  quite  typical  tran- 
sient manic  episodes  as  the  patient  for  the  time  being  resorts  to  an 
extroversion  mechanism. 

And  finally  the  defenses  even  in  the  midst  of  the  manic  phase 
are  never  quite  sufficient  and  the  repressed  complexes  are  con- 
stantly finding  weak  spots  through  which  they  gain  expression 
in  the  delusion  formations  (delusions  of  great  power,  wealth  and 
happiness)  in  the  particular  form  of  activity  (destructiveness ; 
symbolic  needle  work  and  other  creations ;  decoration,  sometimes 
with  the  aid  of  feces,  etc.)  or  in  the  transient  reactions  (words; 
phrases ;  hallucinatory  voices)  of  the  excitement.  These  produc- 
tions are  naturally  quite  like  those  found  in  other  psychoses,  par- 
ticularly the  introverted  group  (precox)  and  lead  often  to  a  con- 
fusion in  diagnosis.  The  important  thing  is  not  to  give  a  name 
but  to  understand  the  mechanism — what  the  patient  is  trying  to 
accomplish. 

Course  and  Prognosis. — The  individual  attacks  vary  in  dura- 


MANIC-DEPRESSIVE   PSYCHOSES.  1 29 

tion  from  a  few  days  to  several  months,  some  attacks,  however, 
being  greatly  prolonged.  Recovery  from  the  single  attack  is  the 
rule,  while  the  likelihood  of  subsequent  attacks  is  quite  certain. 
The  prognosis  for  this  disease  is  therefore  bad  as  to  ultimate 
recovery,  although  good  for  the  separate  attacks.  Sudden  onset 
is,  on  the  whole,  rather  indicative  of  as  sudden  recovery  and 
future  attacks  may  be  presumed  to  follow,  in  general,  the  course 
of  the  past  ones.  As  the  years  go  by  the  attacks  are  apt  to 
recur  with  greater  frequency,  the  quiescent  periods  becoming 
shorter  and  shorter,  though  even  after  a  great  number  there 
may  be  no  evidences  of  mental  deterioration  unless,  perchance, 
the  reduction  of  senescence  has  supervened  meantime. 

There  has  been  some  discussion  as  to  whether  recovery  from 
the  separate  attacks  is  a  true  restitution  to  mental  health  or 
whether  the  patient  does  not,  as  a  matter  of  fact,  show  symptoms 
of  the  disorder  in  the  intervals.  'Contrary  views  are  held  on  this 
point.  It  should  be  recalled,  in  this  connection,  that  recent  re- 
search has  indicated  that  this  group  of  disorders  develops  in  char- 
acters which  have  a  manic-depressive  coloring,  that  is,  which  show 
tendencies  to  depressions  and  excitements  not  sufficiently  well 
marked  to  be  called  disease.  Recovery  certainly  takes  place  so 
far  as  all  practical  issues  are  concerned.  The  patient  has  been 
able  to  push  the  conflict  into  the  unconscious,  and  thus  attains  a 
capacity  to  do  useful  work. 

Differential  Diagnosis. — The  manic  stage  may  be  confused 
with  the  excitement  of  dementia  precox.  The  presence  of  signs 
of  deterioration  in  this  latter  disease,  however,  will  usually  make 
the  diagnosis,  though  there  are  cases  that  are  extremely  difficult 
to  differentiate  and  considerable  time  must  be  allowed  to  elapse 
before  a  diagnosis  can  be  made. 

The  depressive  stage  is  more  apt  to  be  confounded  with  the 
melanchoha  of  the  involutional  period:  particularly  is  this  true  of 
the  mixed  state  of  agitated  depression. 

The  excited  and  stuporous  states  of  catatonia  may  be  con- 
founded. The  excitement  of  catatonia  does  not  show  typical 
flight — the  degree  of  incoherence  is  often  out  of  all  proportion 
to  the  grade  of  excitement.  The  stupor  of  catatonia  is  often 
associated  with  negativism  and  muscular  tension,  while  the  face 
is    either   expressionless   or   perhaps   grimacing.     In   depressive 


130  OUTLINES   OF   PSYCHIATRY. 

Stupor  the  facial  expression  often  shows  the  great  mental  suffer- 
ing of  profound  depression. 

The  great  general  principle  of  diagnosis  in  this  disease,  aside 
from  the  presence  of  the  classical  symptoms,  is  the  occurrence 
of  repeated  attacks.  A  history  of  previous  attacks,  perhaps  too 
mild  to  be  considered  as  such  by  the  family,  will  almost  always 
be  brought  out  by  careful  questioning.  Next  in  importance  to 
the  history  of  repeated  attacks  is  the  history  of  attacks  of  both 
manic  and  depressive  character,  often  showing  at  their  onset  or 
termination  a  short  period  of  a  mixed  state. 

It  must  not  be  forgotten,  however,  that  all  acute  psychoses  tend 
to  recur.  The  individual  once  having  suffered  from  mental  dis- 
ease has  thereb}-  a  diminished  resistance  which  often  shows  itself 
in  future  attacks. 

Pathology. — There  are  no  somatic  findings  which  can  be  desig- 
nated as  characteristic  of  this  disease,  although  a  number  of 
vegetative  neurological  disturbances  are  invariably  present. 
Patients  dying  during  an  attack  almost  invariably  succumb  to 
some  intercurrent  affection,  so  that  any  changes  primarily  pro- 
duced by  the  disease  would  be  greatly  if  not  altogether  obscured. 

Treatment. — Many  of  the  cases  of  hypomania  requires  seques- 
tration because  of  their  tendency  to  commit  alcoholic  and  sexual 
excesses  and  to  make  foolish  financial  ventures. 

The  more  excited  cases  have  to  be  guarded  particularly  against 
exhaustion.  To  this  end  great  care  should  be  taken  to  see  that 
sufficient  food  is  taken  and  prompt  recourse  had  to  artificial  feed- 
ing if  necessary.  For  the  insomnia  hot  milk  at  bedtime,  hydro- 
therapy (hot  pack  or  bath)  and  hypnotics  should  be  tried  in  the 
order  named: — sulfonal,  trional,  veronal,  chloralimid — while 
chloral  and  bromides,  unless  indicated  for  some  special  reason, 
should  be  avoided.  For  the  motor  restlessness  watch  the  patient 
and  keep  him  from  injuring  himself.  Resort  may  be  had  to  the 
wet  pack  or  the  continuous  bath.  If  these  means  fail  hyoscya- 
mine  may  be  used  hypodermically.  Three  to  five  minims  of  the 
centesimal  solution  of  the  amorphous  sulphate  of  hyoscyamine 
with  an  equal  quantity  of  Magendie's  solution  usually  works 
nicely.  The  patient  should  always  be  kept  under  close  observa- 
tion after  such  an  injection  and  as  the  effects  are  quite  disagree- 
able and  often  continue  during  the  next  day  it  should  not  be 


MANIC-DEPRESSIVE    PSYCHOSES.  I3I 

repeated  unless  absolutely  necessary.  The  judicious  use  of  hydro- 
therapy, however,  will  usually  make  it  unnecessary  to  resort  to 
restraint  either  mechanical  or  chemical.  For  the  exhaustion, 
hypodermoclysis  is  often  valuable. 

In  the  depressed  cases  care  should  be  exercised  to  see  that 
sufficient  food  is  taken,  the  emunctories  watched,  and  the  patient 
kept  under  continuous  observation  since  suicidal  trends  are  almost 
invariably  present. 

Phophylaxis. — It  is  important  to  sufficiently  analyze  these  cases 
to  determine  the  conditions  which  led  to  the  breakdown  so  that 
when  the  patient  recovers  appropriate  steps  may  be  taken  to 
protect  him  from  a  recurrence  of  these  same  conditions.  The 
conditions  should  be  removed  or  the  patient  removed  from  them 
or  if  they  are  inevitable,  such  as  incompatible  home  relations,  the 
patient  should  be  advised  how  to  attempt  to  adjust  to  them.  The 
interval  between  attacks  is  the  appropriate  time  for  essaying  a 
psychoanalytic  approach  to  the  patient's  difficulties. 


CHAPTER  X. 

Paresis. 

General  Characterization. — General  paresis  is  am  organic  dis- 
ease of  the  brain  of  an  inflammatory  and  degenerative  nature, 
involving  in  the  main  the  leptomeninges  and  the  cortex  and  mani- 
festing itself  by  certain  physical  symptoms  and  a  progressive  men- 
tal deterioration  upon  which  may  be  engrafted  various  other 
symptoms  of  mental  disturbance. 

Etiology. — The  etiology  of  paresis  has  long  been  a  matter  of 
contention  but  the  opinion  that  syphilis  is  a  necessary  pre-condi- 
tion to  the  development  of  the  disease  has  been  held  for  a  con- 
siderable time  and  is  at  the  present  time  a  settled  issue.  The  sero- 
logical findings  are  positive  for  syphilis  and  the  treponema  pallida 
has  been  found  in  the  paretic  cortex.  Paresis,  in  other  words,  is 
a  form  of  syphilis.  The  terms  meta-  and  para-syphilis  are  in  a 
sense  misnomers.  It  would  be  better  perhaps  to  take  the  key  from 
the  pathology  and  designate  it  as  a  parenchymatous  syphilis.^ 

General  Considerations. — Protean  as  are  the  manifestations  of 
this  disease,  it  is  not  strange  that  it  should  often  go  unrecognized 
during  its  early  stages,  yet  there  is  probably  no  disease  in  which 
a  failure  to  make  a  correct  diagnosis  is  fraught  with  such  mani- 
fest dangers,  not  only  to  the  patient  but  to  his  family,  his  friends, 
or  in  fact  to  any  one  who,  not  recognizing  his  condition,  may  be 
induced,  for  instance,  to  enter  into  business  relations  with  him. 
It  is  during  this  early  period  that  those  unfortunate  occurrences 
are  so  frequent  which  might  have  been  prevented  if  the  true  con- 
dition of  the  patient  had  been  recognized. 

Manifesting  itself  in  its  incipiency  by  symptoms  of  defective 
intelligence,  lack  of  judgment,  memory  defects,  and  moral  obtuse- 
ness,  we  frequently  see  the  most  pitiful  of  pictures — a  previously 
respected  citizen,  father  of  a  family,  occupying  an  enviable  social 
position,  become  at  the  height  of  his  career  an  ardent  worshiper 
at  the  shrines  of  Venus  and  Bacchus.     Friends  and  relatives  see 

^JellifFe  and  White:  Diseases  of  the  Nervous  System,  2d  Ed.,  1917. 

132 


PARESIS.  133 

nothing  in  these  manifestations  but  the  outcropping  of  original 
sin  and  are  distracted  by  their  inability  to  stay  the  career  of 
drunkenness  and  vice  upon  which  their  erstwhile  respected  rela- 
tive has  entered.  How  many  heartaches,  how  many  pangs  of 
anguish,  how  many  blushes  of  shame  could  be  spared  the  wife 
and  children  of  such  a  man  if  the  family  physician  did  but  recog- 
nize in  these  occurrences  the  symptoms  of  the  onset  of  a  mental 
disease  and  advise  them  what  course  to  pursue ! 

An  acute  attack  of  maniacal  excitement,  the  delirium  of  an 
acute  toxic  psychosis,  are  early  recognized  and  even  the  slowly 
developing  depression  of  the  melancholic,  or  the  gradual  change 
of  character  of  the  paranoiac,  is  usually  appreciated  before  any 
serious  harm  can  come.  But  here  we  have  a  disease,  afflicting 
one  when  at  the  very  zenith  of  his  physical  and  mental  powers, 
insidious  in  its  onset  yet  capable  of  so  changing  the  character  in 
a  few  weeks  that  the  previously  honest,  upright,  moral,  truth- 
loving,  sober  citizen  becomes  the  votary  of  every  form  of  vice, 
sinks  to  the  depths  of  drunkenness  and  debauchery,  and  may 
even  stain  his  hands  in  blood.  But  this  is  not  the  worst ;  all  these 
things  would  ultimately  find  their  explanation  when  the  disease 
that  was  responsible  for  them  came  finally  to  be  recognized  and 
in  the  light  of  its  diagnosis  they  would  be  excused.  But  it  so 
happens  that  such  a  man  as  I  have  pictured  is  generally  the  guar- 
dian of  the  family  exchequer.  When  this  is  the  case  it  almost 
invariably  happens  that  he  wastes  considerable  amounts  of  money 
in  his  debauchery,  becomes  involved  in  unfortunate  and  ill-advised 
speculations,  often  at  the  solicitation  of  "  sharpers  "  who  only  too 
well  appreciate  his  poor  judgment  and  gullibility — and  finally, 
when  he  has  succeeded  in  hopelessly  entangling  his  business  af- 
fairs and  plunging  himself  into  debt,  he  is  committed  to  an  insti- 
tution and  his  family  only  then  come  to  a  realization  that  they  are 
penniless.    The  pity  of  it  all  is  that  it  might  have  been  prevented. 

Before  taking  up  the  description  of  this  disease,  it  is  desirable 
to  correct  two  pretty  generally  diffused  misapprehensions  regard- 
ing it.  First,  the  diagnosis  of  paresis  does  not  rest  solely  upon 
the  mental  symptoms.  Paresis  is  a  gross  organic  syphilitic 
disease  of  the  brain  and  its  diagnosis  must  rest  largely  upon  an 
appreciation  of  the  physical  signs  which  these  changes  bring 
about,  particularly  in  the  field  of  motor  disturbance.     Second, 


134  OUTLINES    OF   PSYCHIATRY. 

grandiose  delusions  of  great  wealth,  power  and  strength  are  in  no 
wise  a  necessary  part  of  the  symptom  picture,  and  while  the  so- 
called  classical  type  of  paresis  does  present  such  delusions  this 
type  is  becoming  relatively  less  frequent,  as  the  other  forms  are 
being  oftener  recognized. 

For  convenience  of  description  paresis  may  be  arbitrarily  di- 
vided into  three  periods.  First,  the  prodromal  period;  second, 
the  period  of  the  fully  developed  disease;  and  third,  the  terminal 
period. 

First  Period. 

Physical  Symptoms. — Of  these  by  far  the  most  important  are 
the  oculo-motor  and  tendon  reflex  disturbances.  In  the  oculo- 
motor phenomena  the  pupillary  abnormalities  are  most  important. 
The  loss  of  the  light  reflex  with  retention  of  the  reaction  to  ac- 
commodation, the  Argyll-Robertson  pupil,  is  one  of  the  most  val- 
uable diagnostic  signs  of  beginning  paresis,  in  the  absence  of  tabes, 
as  it  frequently  occurs  very  early.  This  symptom  is  present  in  45 
per  cent,  of  cases.  A  sluggish  reaction  to  light,  probably  the  be- 
ginning stage  of  the  Argyll-Robertson  pupil,  is  found  in  28.3  per 
cent.,  while  a  normal  light  reflex  is  present  in  26.3  per  cent.  It 
is  generally  conceded,  however,  that  the  Argyll-Robertson  pupil 
is  much  more  common  in  the  tabetic  type  of  paresis — 84  per  cent. 
(Bumke).- 

In  this  connection  the  observations  of  Marandon  de  ^Montyel,^ 
published  in  June,  1905,  are  interesting. 

This  author  has  made  observations  of  the  light  reflex  upon 
140  paretics  from  the  beginning  of  the  disease  until  death.  Fifty 
of  the  patients  died  in  the  first  stage,  36  in  the  second,  and  54  in 
the  third.  Of  the  54  who  lived  through  the  entire  evolution  of 
the  disease  every  one  showed  some  abnormality  at  one  time  or 
another.  Of  the  140  patients,  the  reflex  was  always  normal  in 
24  per  cent.,  always  abnormal  in  17  per  cent.,  and  alternated  in 
58  per  cent.  Taken  by  stages,  in  the  first  stage,  42  per  cent,  were 
always  normal ;  the  second  stage,  29  per  cent.,  and  in  the  third, 
3  per  cent.  Those  always  abnormal :  first  stage,  24  per  cent. ; 
second,  34  per  cent.,  and  third,  85  per  cent.    Those  which  alter- 

~  Bumke :  Die  Pupillenstorungen  bei  Geistes  unci  Nervenkrankhciten. 
Verlag  von  Gustav  Fischer  in  Jena,  1904. 

3  E.  Marandon  de  Montyel :  Le  reflexe  lumineux  dans  la  paralysie  gen- 
erale,  Arch.  d.  Neurologic,  Juin,  1905. 


PARESIS.  135 

nated :  first  stage,  32  per  cent. ;  second,  35  per  cent.,  and  third,  1 1 
per  cent.  In  the  first  stage  6  per  cent,  were  exaggerated  in  both 
eyes;  10  per  cent,  showed  diminution  and  abolition  of  the  reflex 
in  one  eye. 

The  author  claims  that  this  is  the  first  complete  series  of  cases 
and  that  the  conclusions  are  much  more  reliable  than  those  based 
upon  a  much  larger  number  of  isolated  observations  taken  at 
random  in  the  disease. 

In  examining  for  these  conditions  care  should  be  taken  that 
movements  of  accommodation  are  not  mistaken  for  reactions  to 
light  by  having  the  patient  fix  the  gaze  upon  some  object,  the 
pupils  should  be  equally  illuminated,  and  the  light  should  not  be 
too  bright,  as  under  these  circumstances  a  sluggish  reaction  might 
be  masked. 

Earlier  still  than  loss  of  the  direct  light  reflex,  Berkeley*  be- 
lieves, can  often  be  found  loss  of  the  consensual  light  reflex.  The 
consensual  reflex  consists  in  the  dilatation  and  contraction  of  the 
pupil  of  one  eye  when  the  other  is  shaded  or  exposed  to  direct 
light.  It  is  quite  possible,  I  believe,  that  the  loss  of  this  reflex  is 
an  early  stage  in  the  development  of  the  Arygll-Robertson  pupil 
and  should  always  be  tested  for.  This  condition  is  usually  found 
when  a  sluggish  light  reflex  is  present.  Lewis^  claims  that  a  still 
earlier  symptom  than  any  of  these  is  the  loss  of  the  sympathetic 
reflex  (the  dilatation  of  the  pupil  on  stimulating  the  skin  of  the 
neck).  Sixty-three  and  six  tenths  per  cent,  of  his  cases  showed 
this  s)miptom,  several  of  them  with  light  and  consensual  reflexes. 

Of  the  tendon  reflexes  the  only  one  I  will  here  consider  is  the 
knee-jerk.  This  may  be  normal,  exaggerated,  diminished  or  lost 
on  one  or  both  sides.  The  exaggerated  reflex  is  most  common, 
but  I  agree  with  Sommer*'  in  his  statement  that  although  this  is 
so  the  absence  of  the  knee-jerk  is  of  much  greater  diagnostic 
importance,  as  there  are  many  more  causes  for  its  exaggeration 
other  than  paresis  than  there  are  for  its  abolition.  This  sign,  also, 
of  course,  depends  for  its  importance  upon  the  elimination  of 
other  possible  etiological  factors,  especially  tabes. 

■*  Berkley,  Henry  J. :  A  Treatise  on  Mental  Diseases.  New  York,  D. 
Appleton  &  Co.,  1900. 

5  Lewis,  W.  Bevan:  A  Text-Book  of  Mental  Diseases.    London,  1899. 

6  Sommer,  Robert :  Diagnostik  der  Geisteskrankheiten.  Berlin  und  Wein, 
1901. 


136  OUTLINES    OF    PSYCHIATRY. 

Mental  Symptoms. — The  mental  symptoms  of  the  prodromal 
period  are  often  not  appreciated  at  the  time  of  their  occurrence 
but  only  after  the  disease  has  been  recognized  in  its  fully  devel- 
oped state  and  then  in  looking  back  over  the  past  few  months 
various  occurrences  which  were  then  not  appreciated  at  their  true 
value  are  seen  in  their  real  relation  to  the  development  of  the 
disease. 

In  general,  these  mental  symptoms  are  symptoms  of  a  gradual 
change  of  character  and  of  progressively  failing  mental  and  phys- 
ical powers.  There  is  a  beginning  failure  on  the  part  of  the 
patient  to  continuously  apply  himself  to  his  work  and  mental 
application  of  any  sort  soon  brings  on  fatigue ;  memory  is  not 
quite  so  good  and  business  engagements  and  the  details  of  busi- 
ness are  forgotten,  the  morale  of  the  patient  is  quite  apt  to 
undergo  alteration,  and  he  may  go  to  excess  in  drinking  and  asso- 
ciate with  lewd  women  oftentimes  openly,  without  shame,  which 
is  of  course  of  most  significance  if  contrary  to  his  previous  habits 
and  ideals.  In  addition  to  these  symptoms  he  shows  poor  judg- 
ment in  his  business  relations  and  may  not  only  risk  large  sums 
of  money  on  hair-brained  schemes,  but  may  enter  into  all  sorts  of 
financial  relations  with  persons  and  preserve  no  records  to  show 
what  they  were. 

The  appearance  of  the  patient  may  also  indicate  the  beginning 
of  mental  reduction;  he  is  less  careful  about  his  personal  appear- 
ance, wears  soiled  linen,  has  forgotten  to  button  his  vest,  or  to 
put  on  a  necktie ;  his  clothes  are  shabby  and  soiled,  and  in  general 
the  degradation  toward  which  his  condition  is  tending  has  begun 
to  show  itself. 

The  mental  symptoms,  as  already  indicated,  are  symptoms  of 
dementia,  gradual,  progressive,  and  more  or  less  uniform  failure 
of  the  mental  powers  upon  which,  it  is  true,  may  be  engrafted 
a  variety  of  kaleidoscopic  psychotic  pictures,  but  which  inevitably 
and  of  necessity  modify  these  in  a  way  more  or  less  characteristic 
of  the  underlying  defect.  This  dementia  manifests  itself  by  fail- 
ure of  memory,  defective  judgment,  inability  to  apply  the  mind 
consecutively  for  any  length  of  time,  and  failure  of  the  moral 
sense.  The  picture,  from  a  mental  viewpoint,  is  then  one  of  a 
gradually  deepening  dementia,  correlated  with  organic  changes  in 
the  cerebral  cortex,  a  true  organic  dementia.     If  upon  this  basis 


PARESIS.  137 

of  organic  dementia  there  be  erected  mayhap  symptoms  of  excite- 
ment or  depression,  delusions  of  a  hypochondriacal  or  grandiose 
nature,  multiform  hallucinations  and  illusions,  a  true  delirium, 
these  symptoms  may  properly  be  considered  as  unessential,  acci- 
dental accompaniments.  Thus  a  distinction  is  made  between  para- 
lytic dementia,  the  direct  result  of  the  destruction  of  brain  tissue 
and  the  fundamental  symptom  on  the  mental  side  of  the  disease, 
and  paralytic  psychosis,  which  consists  of  the  various  other  symp- 
toms of  mental  disturbance  which  may  be  engrafted  on  the  de- 
mented background. 

Developing  as  they  do,  however,  upon  a  groundwork  of  de- 
mentia, we  would  expect  them  to  manifest  themselves  differently 
than  would  be  the  case  if  their  foundation  had  been  originally  an 
unimpaired  mind.  This  we  find  preeminently  to  be  the  case. 
The  grandiose  paretic  is  not  content  with  possessing  a  few  paltry 
thousands  but  reckons  his  fortune  by  quintilHons ;  he  has  solid 
gold  carriages,  harnesses  set  in  precious  stones  and  offers  me  each 
morning  a  fleet  of  ships  to  go  around  the  world  with,  a  million 
dollars  and  a  thousand  wives.  The  depressed  paretic  has  caused 
the  death  of  untold  myriads  of  human  beings,  the  hypochondriacal 
has  no  stomach,  no  bowels,  no  brains,  etc.  The  delusions  are 
marked  by  an  absurdity  which  can  only  result  from  the  defective 
judgment  and  impaired  intelligence  of  dementia. 

These  advanced  conditions  of  delusional  states  are  not  usually 
found  in  this  period  of  the  disease  but  belong  typically  to  the  next, 
the  period  of  full  development.  They  are  quoted  here  merely  to 
illustrate  fully  what  is  meant  by  the  statement  that  the  dementia 
of  paresis  is  the  underlying  and  essential  symptom.  The  demented 
type,  without  marked  delusions  or  sensory  falsifications,  is  the 
truly  typical  variety  of  the  disease  and  the  dementia  the  basal  ele- 
ment of  all  forms. 

This  dementia  may,  however,  not  be  apparent ;  it  may  be  neces- 
sary to  seek  for  its  manifestations.  In  the  very  early  stages  the 
outward  symptoms  may  be  those  of  irritability  and  an  untoward 
restlessness  which  may  exhibit  itself  in  many  ways,  as,  for  in- 
stance, useless  business  activity,  fits  of  violent  rage  over  trivial 
annoyances,  and  slight  lapses  of  memory.  If  the  reasons  for  all 
these  things  be  inquired  into,  however,  they  will  be  found  inade- 
quate, often  puerile. 


138  OUTLINES  OF  PSYCHIATRY, 

We  often  find  in  this  sta^e  of  the  disease  the  beginnings  of 
those  speech  defects  which  later  are  to  become  so  characteristic. 
At  this  time  there  may  be  only  a  suspicion  of  the  true  paretic 
speech  in  the  slight  hesitation  and  occasional  almost  unnoticeable 
defect  in  a  single  word.  Such  patients  often  say  test  words,  such 
as  hippopotamus,  communicability,  circumstantiality,  perambula- 
tor, quite  correctly.  It  would  seem  that  the  defect  is  as  yet  so 
slight  that  the  mere  effort  as  the  result  of  conscious  attention  is 
sufificient  to  overcome  it.  In  such  cases  the  test  words  should  be 
combined  into  sentences  to  catch  the  patient  unawares,  as  it  were. 
I  had  a  patient  who  said  test  words  and  phrases  perfectly,  yet 
there  was  a  noticeable  defect  in  an  occasional  word  in  her  ordinary 
conversation.  If  she  were  asked,  however,  to  repeat  this  word  it 
was  done  promptly  and  correctly.  If  the  speech  defect  is  slightly 
more  marked  we  may  notice  a  slight  tremor  about  the  muscles  of 
the  mouth  which  is  brought  out  by  a  difficult  word  or  by  emotional 
excitement.  We  should  be  careful  in  interpreting  this  tremor, 
however,  as  we  find  it  present  in  many  conditions  other  than 
paresis. 

Second  Period, 

Physical  Symptoms. — The  symptoms  already  described  become 
more  marked.  The  tremor  especially  is  more  in  evidence  and  is 
of  the  fibrillary  variety ;  the  muscular  weakness  is  noticeable  and 
is  in  marked  contrast  to  the  well-nourished  appearance  of  the 
patient,  who  quite  characteristically  takes  on  flesh  in  this  stage ; 
the  Romberg  symptom  becomes  much  more  marked,  so  that  the 
patient  may  fall  when  the  eyes  are  shut ;  the  walk  is  more  ataxic — 
especially  in  those  cases  that  have  begun  with  tabetic  symptoms — 
the  tabetic  variety.  Certain  cases  in  which  focal  symptoms  are 
clinically  pronounced  are  referred  to  as  Lissauer's  type. 

Characteristic  of  paresis,  and  occasionally  but  not  frequently 
occurring  early  in  its  course,  are  the  so-called  paretic  seizures 
which  arbitrarily  may  be  said  to  mark  the  beginning  of  the  second 
stage.  These  may  vary  in  severity  and  character  from  light  syn- 
copal attacks  with  pallor  and  temporary  prostration  to  severe  apo- 
plectiform and  epileptiform  crises.  The  epileptiform  attacks  may 
be  of  the  petit  mal  or  grand  mal  type  and  without  the  history  may 
be  indistinguishable  from  true  epilepsy. 

These  epileptiform  seizures  may  be  severe  or  slight  and  may 


PARESIS.  139 

involve  any  portion  of  the  musculature  and  be  accompanied  by 
loss  of  consciousness  or  not.  Occasionally  a  seizure  is  the  first 
symptom  to  attract  attention,  and  if  the  patient  is  alcoholic,  it 
may  under  such  circumstances  be  extremely  difficult  to  make  a 
diagnosis  from  alcoholic  epilepsy.  In  general,  the  seizures  last 
longer  than  the  epileptic  convulsion,  and  occurring  in  a  person 
thirty  to  forty  years  of  age  without  previous  history  of  epilepsy 
or  alcoholism,  should  at  once  suggest  paresis.  They  are  less  apt 
to  be  associated  with  loss  of  consciousness.  Occasionally  these 
seizures  last  for  days,  the  muscular  twitching  spreading  from  one 
part  of  the  body  to  another,  with  clouding  of  consciousness  but 
not  complete  unconsciousness  all  of  the  time.  There  may  also 
be  conjugate  deviation  of  the  eyes  and  in  many  cases  a  marked 
rise  of  temperature.  Under  such  circumstances  pneumonia  is  par- 
ticularly to  be  feared  as  a  fatal  intercurrent  disease. 

The  apoplectiform  seizures  resemble  in  every  way  true  apoplexy 
but  the  resulting  paralysis  is  less  apt  to  be  permanent ;  in  fact,  it 
may  entirely  disappear  in  a  most  remarkable  fashion  in  two  or 
three  days.  It  must  not  be  forgotten  that  the  paretic  may,  of 
course,  have  a  frank  apoplectic  attack  with  resulting  permanent 
paralysis.  Transitory  muscular  paralyses,  not  infrequently  of  the 
extrinsic  eye  muscles,  may,  however,  occur  apart  from  these 
seizures.    They  are  of  short  duration  and  clear  up  rapidly. 

After  a  seizure  it  is  usual  to  find  that  the  patient  is  somewhat 
more  demented.     This  is  a  distinguishing  feature  from  epilepsy. 

The  cause  of  these  seizures  cannot  be  satisfactorily  explained, 
but  they  are  perhaps  due  to  local  conditions  in  the  brain  of  both 
toxicity  and  edema.  They  may  be  explained  as  a  result  of  the 
extensive  destructive  process  going  on  and  the  clogging  of  the 
Imyph  channels,  so  that  the  waste  products  cannot  be  removed 
readily. 

Mental  Sypmtoms. — The  mental  symptoms  of  this  period  are 
merely  more  exaggerated  expressions  of  those  already  described. 
The  symptoms  of  mental  reduction — dementia — become  more  and 
more  prominent.  Memory  fails  utterly,  so  that  the  patient  may 
not  recall  the  location  of  his  room  that  he  has  lived  in  for  weeks ; 
spatial,  temporal  and  personal  disorientation  appear ;  a  true  occu- 
pation delirium  may  develop,  the  patient  being  often  found  carry- 
ing on  his  accustomed  business  operations  oblivious  of  his  sur- 


I40  OUTLINES   OF   PSYCHIATRY. 

foundings;  the  simplest  mental  operations,  such  as  adding  a 
column  of  figures,  have  become  impossible;  the  emotional  de- 
terioration is  prominent,  the  patient  pays  no  attention  to  his  fam- 
ily and  may  not  be  affected  even  by  the  death  of  one  of  them.  The 
speech  disturbance  which  has  been  in  evidence  usually  for  some 
time  becomes  much  more  prominent.  Syllables  are  reduplicated, 
words  are  left  out  or  stumbled  over,  the  voice  is  harsh  and  lack- 
ing in  expression.  The  writing  presents  similar  defects  and  al- 
though sometimes  the  first  few  words  are  fairly  done  soon  be- 
comes almost  absolutely  illegible,  a  mass  of  scrolls,  blots,  erasures, 
or  the  patient  may  fail  absolutely  after  several  efforts  to  write 
at  all. 

In  this  fully  developed  stage  the  disease  occurs  in  four  types, 
viz.,  the  demented,  excited,  agitated  and  depressed. 

The  demented  type,  as  has  been  explained,  constitutes  the 
typical  variety  of  the  disease  and  is  the  type  which  has  been  thus 
far  described. 

The  excited  or  expansive  type  is  marked  by  more  active  symp- 
toms and  typically  by  grandiose  delusions.  This  constitutes  the 
so-called  classical  paralysis.  These  ideas  of  grandeur  are  marked, 
as  already  explained,  by  their  absurd  character,  the  patients  be- 
lieving themselves  to  have  great  strength,  they  can  lift  enormous 
weights,  have  fabulous  wealth,  so  much  money  in  fact  that  ordi- 
nary words  are  insufficient  to  express  the  amount  and  the  words 
have  to  be  invented  for  that  purpose,  possess  thousands  of 
carriages  with  trimmings  of  gold  and  precious  stones,  fleets  of 
vessels  to  take  friends  on  tours  about  the  world,  write  checks  for 
millions  and  distribute  them  indiscriminately.  One  patient  was 
importing  carloads  of  bloodhounds,  another  has  invented  a  special 
kind  of  axle-grease  and  offers  to  give  thousands  of  carloads  to 
anyone  who  will  introduce  it  to  the  railroads  and  called  to  see  the 
President  to  get  him  to  have  a  law  enacted  so  that  he  could  draw 
upon  the  Treasury  to  finance  his  scheme.  With  these  delusional 
symptoms  there  goes  a  great  deal  of  motor  unrest,  the  patient 
constantly  busies  himself  drawing  up  schemes,  writing  checks, 
talking,  etc.,  and  suffers  from  insomnia. 

The  agitated  type,  sometimes  called  when  extreme  galloping 
paresis,  is  a  more  aggravated  form  of  the  excited  type.  In  this 
condition  the  motor  restlessness  and  insomnia  is  extreme,  there 


PAEESIS.  141 

supervenes  marked  emaciation,  the  delusions,  while  of  the  expan- 
sive type,  are  rapidly  changeable  and  there  is  a  marked  flight  of 
ideas,  with  considerable  clouding  of  consciousness.  Some  tem- 
perature usually  coexists  and  the  case  runs  a  rapidly  fatal  course 
from  exhaustion.  All  grades  of  excitement  may,  of  course,  occur 
between  the  classical  type  on  the  one  hand  and  the  extreme  form 
of  the  agitated  type — galloping  paresis — on  the  other. 

The  depressed  type  is  often  as  first  mistaken  for  melancholia, 
and  this  mistake  is  liable  to  be  made  unless  the  physical  symptoms 
are  borne  in  mind.  The  depression  may  take  the  form  of  de- 
pressive melancholia  with  retardation  or  of  affective  melancholia 
with  anxiety  and  apprehension.  Delusions  are  frequent  and  often 
take  the  form  of  hypochondriacal  ideas — the  bowels  are  stopped 
up,  the  blood  does  not  circulate,  and  the  like,  or  ideas  of  negation, 
the  patient  denying  that  he  has  a  stomach,  brain,  soul,  head,  or 
even  claiming  that  he  is  dead. 

Sometimes  states  of  depression  and  excitement  alternate,  so 
producing  a  circular  paralytic  psychosis. 

Delusions  of  a  presecutory  character  may  give  a  paranoid  type 
to  the  symptom-complex,  while  in  some  cases  the  Korsakoiv  syn- 
drome is  present. 

The  following  brief  summaries  of  cases  illustrate  some  of  these 
points.  The  Wassermann  reactions  and  the  cell  count  of  the 
cerbro-spinal  fluid  should  be  noted. 

This  case  shows  a  long  prodromal  period  with  probably  a  seizure 
very  early  in  the  history.  He  was  first  depressed  and  paranoid, 
then  excited,  and  then  all  these  manifestations  subsided  and  he 
became  quiet  and  showed  simply  the  dementia. 

Male,  age  41 ;  first  evidence  of  any  trouble  began  two  years  ago,  when 
patient  suffered  from  severe  pains  in  both  legs;  they  were  very  acute  and 
severe  in  nature.  In  March,  191 1,  he  had  a  vomiting  spell,  following  what 
is  believed  to  have  been  a  slight  convulsion.  After  this  he  became  peculiar. 
Following  this,  for  certain  irregularities,  he  was  discharged  by  his  em- 
ployers and  subsequently  sent  to  the  Washington  Asylum  Hospital  where 
he  remained  for  two  weeks,  when  he  was  taken  home  by  his  family  on  a 
six  months'  trial.  During  this  time  he  improved.  On  his  return  to  Wash- 
ington, being  unable  to  obtain  employment,  he  became  very  much  depressed, 
thought  that  people  were  against  him,  believing  that  he  was  perfectly  well 
and  able  to  work.  His  mental  condition  became  such  that  his  family  had 
him  admitted  to  the  Laurel  Sanitarium,  where  he  remained  for  five  weeks. 
Shortly  before  admission  to  this  Hospital  there  was  some   sort  of  an 


142  OUTLINES    OF   PSYCHIATRY. 

acute  outbreak,  during  which  he  had  several  convulsions  and  he  became 
unmanageable,  refused  to  remain  in  bed  and  on  this  account  was  brought 
to  this  Hospital. 

Physical  condition  good.  Pupils  regular,  equal,  no  reaction  to  light 
either  directly  or  consensually  but  they  do  react  to  accommodation.  Slight 
nystagmus  in  each  eye  on  external  rotation.  No  ocular  pareses.  Tremors 
of  tongue  and  extended  fingers.  Knee  reflexes  exaggerated,  right  patellar 
decreased,  left  absent.    No  ankle  clonus. 

On  admission  he  was  quite  disturbed,  especially  at  night.  Some  form  of 
mechanical  restraint  was  necessary.  He  threatened  to  fight  the  attendants 
when  any  attempt  to  care  for  him  was  made.  He  was  very  unsteady  on 
his  feet,  unable  to  care  for  himself.  It  was  impossible  to  get  any  history 
from  him  during  early  days  of  his  residence  here.  Irritability  was  very 
marked  and  he  would  often  curse  and  refuse  to  answer  questions.  No  in- 
sight, no  definite  hallucinations  or  delusions.  Two  months  later  (January 
15,  '12)  it  was  noted  that  he  was  becoming  more  quiet,  never  complained, 
and  his  only  request  was  to  be  discharged.    No  insight. 

Since  that  time  patient  has  greatly  improved;  he  is  now  quiet  and 
orderly,  oriented  in  all  fields,  memory  shows  no  gross  impairment,  but  he 
has  no  insight  into  his  condition.  Wassermann  with  blood  serum  double 
positive.  With  the  spinal  fluid  double  positive.  Protein  content  increased, 
42  cells  per  c.mm. 

This  patient  showed  the  typical  grandiose  delusions,  then  a 
change  to  depression  with  a  paranoid  trend,  and  the  occurrence 
of  seizures. 

Admitted  July  25,  191 1,  age  50,  married,  commissary  steward  of  the  U.  S. 
Navy.  Family  history  unimportant.  Early  life  uneventful  so  far  as 
known.  Supposed  syphilitic  infection  in  1902.  First  admitted  to  the  sick 
list  on  June  28,  191 1.  For  several  months  after  this  it  was  noted  that 
he  was  rather  boastful.  Subsequently  very  marked  grandiose  tendencies 
appeared,  he  was  the  Kaiser,  the  President,  head  of  the  Navy,  etc.,  he 
ordered  many  automobiles  and  large  quantities  of  diamonds.  This  condi- 
tion continued  until  his  admission  to  this  hospital  at  which  time  he  was 
exalted,  constantly  going  about  the  ward,  continually  talking  and  at  times 
singing  for  short  intervals.  He  quickly  obeyed  any  requests  made  of  him 
and  followed  all  directions  given  him.  Attention  was  easily  gained  but  not 
well  held.  There  were  many  grandiose  delusions  concerning  his  own  im- 
portance; he  was  Emperor  of  Germany,  Columbus,  DeSoto,  etc.,  in  fact 
anything  which  was  suggested  to  him,  he  discovered  the  world,  other 
patients  about  him  were  his  brothers  who  fought  to  liberate  this  country; 
he  built  this  hospital,  had  an  unlimited  amount  of  money.  He  was  decid- 
edly euphoric,  smiling  and  laughing  most  of  the  time;  had  no  insight. 
Wassermann  reaction  with  the  blood  serum  was  double  positive,  with  the 
spinal  fluid  double  positive.    Protein  content  increased,  cells  49  per  c.mm. 


PARESIS.  143 

For  several  months  following  his  admission,  there  was  no  essential 
change  in  his  condition,  he  continued  active,  euphoric  and  alert,  was  busy 
with  something  throughout  the  entire  day,  constantly  moving  about  the 
ward,  talking  with  other  patients  concerning  his  various  grandiose  delu- 
sions. In  August  there  was  a  slight  convulsive  attack.  Patient  continued 
up  and  about  the  ward  until  about  a  month  ago,  when  he  became  very 
decidedly  depressed,  numerous  ideas  of  persecution  were  expressed,  and 
there  were  auditory  hallucinations,  the  voices  calling  him  all  sorts  of  un- 
pleasant names  and  accusing  him  of  various  unseemly  practices;  he  felt 
electricity  running  through  his  body,  says  his  head  is  all  dried  up  and 
there  is  nothing  left  of  his  body,  what  was  once  his  body  is  nothing  now 
but  a  machine.  He  says  he  has  no  more  money,  that  what  he  talked  about 
was  all  a  delusion,  that  he  is  now  poor  and  has  no  friends. 

This  patient  is  one  of  the  simple  dementing  type. 

Admitted  from  the  District  of  Columbia,  September  8,  1910,  at  the  age 
of  28.  Family  history  unimportant.  During  infancy  and  childhood  patient 
suffered  from  "  night  terrors."  Early  life  was  spent  in  an  orphan  asylum. 
He  has  been  employed  in  Washington  as  a  stationary  engineer  since  1904. 
No  history  of  venereal  infection  or  alcoholism.  Symptoms  of  the  present 
illness  date  back  to  September,  1909,  when  his  work  became  inefficient, 
memory  poor,  and  irritability  became  prominent.  He  was  discharged 
from  his  position  in  January,  1910,  and  has  been  unable  to  obtain  employ- 
ment since  then.  In  April,  1910,  the  first  speech  defect  became  noticeable. 
In  July,  1910,  he  was  sent  to  the  Washington  Asylum  Hospital,  where  he 
remained  one  month.  He  returned  home  but  was  restless,  had  a  poor 
appetite  and  did  not  sleep  well,  so  that  after  a  few  weeks  he  was  again 
returned  to  the  Washington  Asylum  Hospital,  where  he  remained  until 
his  admission  here.  About  three  years  ago  it  was  learned  that  he  had 
some  sort  of  fainting  spell,  accompanied  by  unconsciousness. 

On  admission  here  he  was  only  partially  oriented,  memory  for  past 
events  fairly  well  preserved,  but  impaired  for  recent  ones.  Insight  was 
lacking,  and  he  was  more  or  less  exalted.  No  hallucinations  or  delusions 
could  be  elicited.    Speech  slow  and  enunciation  slurring. 

Physically  he  was  poorly  nourished,  marked  tremor  of  lips  and  tongue 
was  noted.    Pupils  normal.    Tendon  reflexes  exaggerated. 

Wassermann  reaction  with  the  blood  serum  positive,  not  determined  in 
the  spinal  fluid.  Protein  content  of  the  spinal  fluid  increased.  Cells  per 
c.mm.  44. 

For  several  months  after  admission  he  was  indifferent,  quiet  and  apa- 
thetic, showing  no  essential  change  in  his  condition.  In  March,  191 1,  pupils 
showed  absent  light  reaction  and  absent  knee  jerks.  Within  the  past  few 
months,  he  has  shown  a  more  evident  deterioration,  is  somewhat  enfeebled 
and  quite  irritable  when  questioned.  Hallucinations  and  delusions  have 
not  been  manifested.    Convulsions  have  not  occurred. 


144  OUTLINES   OF  PSYCHIATRY. 

The  following  patient  showed  the  typical  grandiose  delusions 
with  great  impairment. 

Oiler  in  the  United  States  Navy,  was  admitted  on  October  5,  191 1,  at  the 
age  of  40.  He  was  first  admitted  to  the  sick  list  on  the  U.  S.  S.  California, 
on  May  29,  191 1.  It  is  stated  that  he  had  shown  progressive  mental  dete- 
rioration for  a  year  past.  Speech  was  scanning  and  there  was  some  hesi- 
tancy. He  had  become  shiftless  and  careless  in  his  work.  No  venereal 
history  was  elicited.  On  July  i,  191 1,  he  was  transferred  to  the  Mendocino 
State  Hospital,  where  he  remained  until  his  admission  here.  The  history 
which  he  can  give  of  his  family  and  past  life  is  quite  unreliable.  He  denies 
venereal  infection  and  alcoholism.  Grandiose  delusions  were  present — he 
was  worth  six  million  dollars,  states  that  he  has  taken  one  thousand 
dollars'  worth  of  medicine,  that  he  had  four  wives  and  about  two  hundred 
and  fifty  children,  claims  that  he  knows  everything  about  machinery, 
automobiles,  has  been  to  the  moon  a  number  of  times  in  aeroplanes,  he 
can  carry  a  lot  of  moons  on  his  aeroplanes,  which  can  travel  about  ninety 
miles  in  fifteen  minutes.  His  responses  to  the  intelligence  tests  show 
marked  deterioration.  He  was  completely  disoriented,  memory  greatly 
impaired  and  insight  entirely  lacking. 

Physical  examination  shows  tremors  of  the  fingers,  tongue  and  facial 
muscles.  Both  knee  jerks  are  exaggerated.  Coordination  and  station  im- 
paired.    Pupillary  light  reaction  absent. 

Wassermann  reaction  with  the  blood  serum  double  positive.  No  history 
of  convulsions.  Progress  has  been  gradual  since  admission.  Condition 
essentially  unchanged. 

This  patient  showed  the  association  of  a  mild  euphoria  with  a 
persecutory  trend. 

Admitted  July  30,  191 1,  age  43;  married.  Family  history  and  early  hfe 
of  the  patient  unimportant  so  far  as  known.  No  history  of  alcoholism, 
drug  addiction  or  venereal  infection.  Symptoms  of  mental  disorder  were 
exhibited  for  more  than  a  month  prior  to  admission,  when  he  had  pro- 
nounced delusions  of  grandeur  and  persecution,  since  then  has  developed 
ideas  of  a  mildly  persecutory  type  associated  with  delusional  tendencies. 
He  threatened  to  kill  himself  and  others. 

On  admission  he  was  quiet,  answered  questions  promptly  and  relevantly, 
was  approximately  oriented.  Close  questioning  made  him  extremely  irri- 
table; this  persisted  only  transiently,  when  he  again  became  quite  happy 
and  almost  euphoric.  In  speaking  or  laughing  there  was  noticed  a  slight 
lack  of  control  of  the  muscles  of  expression  and  there  was  a  decided  over- 
activity of  the  muscles  of  the  face.  Test  phrases  were  very  much  slurred 
and  some  of  them  almost  unrecognizable;  he  had  a  poor  memory;  delu- 
sions of  grandiose  nature  present.  No  insight.  No  hallucinations;  says 
he  never  felt  better  in  his  life.     Pupils  equal,  regular  in  outline,  react  to 


PARESIS.  145 

light  directly  and  consensually  and  to  accommodation.  Knee  jerks  exag- 
gerated.    Responses  to  the  intelligence  tests  fairly  adequate. 

Wassermann  reaction  with  the  blood  serum  double  positive,  with  the 
spinal  fluid  double  positive.  Protein  content  of  the  spinal  fluid  increased. 
Noguchi  positive.    Cells  per  c.mm.  94. 

Since  admission  there  has  been  slight  change  in  this  patient's  condition. 
He  is  quiet  and  orderly,  never  complains,  shows  no  interest  in  his  sur- 
roundings.    He  has  had  one  very  mild  convulsive  attack. 

The  following  is  a  grandiose  type  with  great  impairment,  in 
which  the  delusions  are  not  manifested  spontaneously  but  only 
brought  out  on  questioning. 

Admitted  March  3,  1911,  age  Z7  years;  single;  soldier.  Family  history 
so  far  as  known  unimportant.  Early  life  uneventful.  Probable  history  of 
syphilis  in  1908.  The  onset  of  present  illness  was  sudden  in  February, 
191 1.  Grandiose  tendencies  became  prominent.  He  claimed  he  was  a  great 
preacher,  that  he  was  going  to  evangelize  the  world,  says  he  has  fifty 
thousand  dollars,  confers  rank  upon  attendants  as  captains,  colonels,  and 
brigadier  generals;  is  a  great  painter  and  artist.  Is  very  happy,  euphoric 
and  talkative. 

On  admission  to  this  hospital,  his  condition  in  no  way  having  changed, 
he  was  very  happy,  euphoric,  there  were  marked  grandiose  tendencies,  he 
is  the  strongest  man  in  the  world,  has  an  unlimited  amount  of  money; 
partially  oriented,  test  phrases  poorly  pronounced,  marked  slurring.  Knee 
jerks  exaggerated,  left  pupil  larger  than  the  right,  react  to  light  directly 
and  consensually  with  slight  excursion.  Physical  examination  shows  him 
to  be  somewhat  emaciated,  otherwise  in  good  general  condition.  Wasser- 
mann with  the  blood  serum  double  positive;  with  the  spinal  fluid  double 
positive.     Protein  content  increased.     Cells  per  c.mm.  82. 

Since  admission  his  condition  has  continued  without  very  great  change. 
Grandiose  delusions  continue  practically  unlimited  in  their  extent.  After 
several  months  he  became  somewhat  more  quiet,  did  not  so  constantly 
mention  his  delusions.  On  questioning,  however,  such  tendencies  were  still 
to  be  elicited.  He  owns  the  entire  hospital,  is  God,  the  President,  etc. 
Attention  is  difficult  to  hold,  he  answers  questions  promptly,  talks  almost 
continuously  in  a  rather  unintelligible  tone.  Both  pupils  still  react  to 
light. 

This  patient  showed  epileptiform  seizures,  marked  confusion, 
and  pronounced  hallucinatory  disturbances. 

Admitted  March  7,  191 1,  age  z^  years;  married;  soldier.  Family  history 
negative.  Early  life  uneventful.  Army  career  of  good  character.  Denies 
alcoholic  indulgence  and  syphilis.  For  a  year  preceding  admission  experi- 
enced some  difficulty  in  attending  to  clerical  work;  could  not  concentrate 
his  mind.    Memory  began  to  fail,  and  he  was  sent  into  the  army  hospital. 


146  OUTLINES   OF   PSYCHIATRY. 

where  he  remained  for  a  short  time,  when  he  secured  a  leave  of  several 
months.  When  he  again  reported  he  was  transferred  to  this  hospital. 
With  the  first  symptoms  were  slight  apoplectiform  attack,  involving  the 
left  side  of  the  body  in  December,  1909,  passing  off  in  24  hours;  disease 
has  been  progressive  since  then. 

On  admission  here,  patient  was  quiet,  speech  apparently  slurred,  enuncia- 
tion poor  even  in  ordinary  conversation.  Test  phrases  were  at  times  very 
indistinctly  pronounced.  Bradylalia.  No  insight.  Orientation  good.  No 
delusions  or  hallucinations.  Right  pupil  larger  than  left;  both  irregular 
in  outline,  absolutely  no  light  reaction;  they  react  to  accommodation. 
Knee  jerks  much  exaggerated.     General  physical  condition  good. 

In  May,  191 1,  a  general  epileptiform  seizure,  following  which  it  was 
noted  that  patient  was  confused,  dazed  and  stupid,  attacked  other  patients, 
and  when  asked  to  explain  his  conduct  said  that  he  had  been  detailed  to 
care  for  them  and  they  would  not  obey  his  orders.  He  became  very  much 
confused,  would  undress  himself  in  the  day  room,  apparently  had  no 
conception  of  his  condition  or  situation  in  general.  During  June,  July 
and  August  this  condition  of  disturbance  continued.  In  September  he  was 
again  improved;  was  up  and  about  the  ward.  He  is  disoriented  in  all 
fields,  has  absolutely  no  insight,  memory  markedly  impaired,  and  an  easily 
detected  speech  defect.  In  November  patient  appeared  somewhat  con- 
fused, auditory  hallucinations  became  very  marked,  and  he  had  been  car- 
rying on  a  conversation  with  the  President,  but  could  hear  these  voices 
only  in  the  left  ear,  in  which  ear,  he  says  he  has  been  somewhat  deaf  for 
a  long  time.  He  says  his  reason  for  not  writing  his  wife  is  that  he  can 
converse  with  her  in  Kansas.  Persecutory  ideas  were  present.  He  thought 
that  one  of  the  other  patients  was  going  to  kill  him.  He  believes  that  his 
restraint  in  bed  for  the  past  several  weeks  is  only  part  of  the  plan  of  this 
patient  to  kill  him.     Since  then  there  has  been  no  change. 

Wassermann  reaction  with  the  blood  serum  double  positive,  with  the 
spinal  fluid  double  positive.  Fluid  clear;  protein  content  increased;  No- 
guchi  positive.    Cells  per  c.mm.  62. 

Third  Period. 

As  the  second  period  may  be  arbitrarily  said  to  be  ushered  in 
by  the  paretic  seizure,  so  the  third  period  may  be  arbitrarily  said 
to  date  from  the  time  when  the  patient  begins  to  soil  himself. 

Physical  Symptoms. — All  the  physical  symptoms  become  more 
marked  in  this  stage.  The  tremor  is  constant,  the  ataxia  has 
increased  to  such  an  extent  that  locomotion  becomes  dangerous 
or  quite  impossible  and  because  of  the  friable  condition  of  the 
bones  falls  are  liable  to  produce  fractures,  muscular  weakness  is 
marked  and  emaciation  becomes  extreme.     In  this  infeebled  con- 


PARESIS.  147 

dition  the  patient  becomes  bedridden,  contractures  quite  often 
develop  in  the  extremities  and  control  of  the  sphincters  is  lost. 
Often  a  contracture  of  the  neck  muscles  develops,  so  that  the  head 
is  kept  raised  from  the  pillows  in  a  characteristic  attitude,  and 
not  infrequenly  the  patient  grinds  the  teeth  for  hours  at  a  time. 
The  paretic  seizures  become  more  frequent,  bed  sores  develop 
over  all  the  bony  prominences  unless  the  most  scrupulous  care  is 
taken  to  prevent  them,  exhaustion  occurs  and  the  patient  dies  in 
a  seizure,  from  marasmus,  or  some  intercurrent  affection. 

Mental  Symptoms. — In  the  mental  sphere,  as  in  the  physical, 
there  continues  to  be  a  progressive  degradation.  The  dementia 
becomes  profound,  so  that  the  patient  may  not  even  know  his  own 
name — he  ceases  absolutely  to  lead  a  mental  life  and  leads  only  a 
vegetative  existence.  Often  in  the  mass  of  stammering,  stum- 
bling, incoherent  sounds  a  word  here  and  there  will  indicate  the 
remains  of  former  delusions.  It  is,  however,  not  uncommon  for 
the  symptoms  of  the  paralytic  psychosis  to  disappear  in  this  stage 
and  for  the  case  to  terminate  in  uncomplicated  dementia.  Finally, 
if  no  intercurrent  malady  supervenes,  the  patient  sinks  into  coma 
and  dies. 

Juvenile  General  Paresis. — Although,  until  recently,  but  com- 
paratively few  cases  of  paresis  in  children  have  been  reported,  it 
undoubtedly  occurs  quite  frequently  but  is  usually  unrecognized. 
The  possibility  of  paresis  should  be  thought  of  in  all  cases  of 
progressive  mental  impairment  in  children. 

The  disease  usually  occurs  in  children  one  or  both  of  whose 
parents  have  had  syphilis.  Syphilis,  of  course,  may  be  acquired 
at  an  early  age.  The  evidences  of  parental  syphilis  should  be 
carefully  sought.  Inquiry  should  be  made  as  to  the  cause  of 
death  of  parents,  their  age,  miscarriages  in  the  mother,  etc.  In- 
quiry should  also  be  directed  to  determine  early  signs  of  heredi- 
tary syphilis  in  the  patients,  such  as  snuffles,  sore  eyes,  etc.  The 
patient  may  bear  the  scars  of  syphilis,  such  as  saddle-nose,  cor- 
neal ulcers,  enlarged  glands,  scars  about  the  corners  of  the  mouth, 
Hutchinson  teeth,  etc. 

The  disease  usually  comes  to  notice  from  about  twelve  to  four- 
teen years  of  age.  The  early  symptoms  may  be  largely  motor, 
such  as  clumsiness  in  walking  and  stumbling.  With  this  is  com- 
bined a  beginning  disturbance  of  speech  and  inquiry  will  develop 


148  OUTLINES   OF   PSYCHIATRY. 

that  the  child  has  seemed  somewhat  dull  lately  at  school.  The 
early  picture  not  infrequently  reminds  one  of  the  picture  of 
Friedreich's  ataxia. 

From  the  development  of  these  early  symptoms  there  is  a 
progressive  mental  decay  usually  of  the  simpler  dementing  type. 
School  knowledge  is  finally  absolutely  lost  and  the  dementia  be- 
comes profound.  There  is  also  a  steady  progress  in  the  motor 
symptoms.  These  cases  seem  to  develop  contractures  of  the  ex- 
tremities quite  early  and  to  become  absolutely  helpless. 

All  the  usual  signs  of  paresis  are  found,''  both  clinically  and 
anatomically. 

Gross  Pathology. — In  opening  the  calvarium  the  dura  is  found 
abnormally  adherent  to  the  skull  cap  and  internally  may  present 
areas  of  hemorrhagic  pachymeningitis.  The  surface  of  the  brain 
shows  areas  of  congestion  more  frequently  in  the  frontal,  parietal 
and  temporal  regions  than  in  the  occipital.  The  leptomeninges 
are  thickened,  opaque,  and  along  the  lines  of  the  great  vessels 
contain  a  milky,  opalescent  fluid.  In  attempting  to  remove  them 
they  are  found  abnormally  adherent,  so  that  portions  of  the  cortex 
are  torn  off  with  them — decortication — giving  a  worm-eaten  ap- 
pearance to  the  denuded  surface.  This  appearance  is  very  char- 
acteristic and  is  almost  always  present,  except  perhaps  early  or 
in  the  very  late  stages  when  a  subpial  collection  of  serum  has 
raised  the  membranes  from  the  brain  so  far  that  they  may  be 
readily  removed.  The  brain  as  a  whole  is  shrunken  and  when 
opened  the  ependyma  is  found  typically  to  be  granular. 

Histopathology. — The  monumental  work  of  Alzheimer'  is  the 
authority  on  the  microscopic  changes  in  this  disease.  He  gives 
an  abstract  of  these  changes  as  follows : 

Blood  Vessels. —  (a)  One  of  the  most  striking  features  is  the 
marker  proliferation  of  new  capillaries.  These  are  often  ex- 
tremely rich,  often  showing  like  a  thick  net-work  of  capillary 
meshes.  These  are  the  product  of  an  active,  productive,  inflam- 
matory process,  and  come  about  through  the  very  rich  formation 
of  new  endothelial  cells,  and  branching  and  vascularization  of 

7  Hough,  Wm.  H. :  A  Case  of  Juvenile  General  Paresis,  Jour.  Nerv.  and 
Ment.  Dis.,  Oct.,  1909. 

8  Alzheimer :  Histologische  Studien  zur  Differentialdiagnose  des  Prog- 
ress. Paralyse.    Hist,  und  histopath,  Arbeiten,  Bd.  I,  1904. 


PARESIS.  149 

the  regenerating  intima.     This  new  vessel  formation  in  some  cases 
is  excessive,  in  others  less  noticeable. 

(b)  There  results  an  increase  of  elastic  tissues  by  the  forma- 
tian  of  new  net-works  about  the  proliferating  endothelial  cells 
and  a  formation  of  stronger  membranes. 

(c)  A  proliferation  of  the  adventitia  also  results,  at  times 
slight,  again  very  marked. 

(d)  A  dilatation  and  infiltration  of  the  adventitial  lymph  spaces. 
The  infiltrating  cells  are  largely  made  up  of  plasma  cells.  [The 
origin  of  these  cells  has  not  been  satisfactorily  explained.  Whether 
they  are  transformed  leukocytes  or  derived  from  the  connective 
tissue  is  a  mooted  question.]  They  are  never  absent  even  in  the 
most  acute  cases.  Lymphocytes  and  mast-cells  are  also  common 
in  the  lymph  spaces. 

(e)  In  most  of  the  advanced  cases  of  paresis,  degenerative 
changes  are  common  in  the  blood  vessels,  especially  in  the  upper 
cortical  layers.  A  complete  destruction  of  the  vessels  may  take 
place  and  hyaline  degeneration  result. 

(/)  In  the  cortex  of  the  paretic,  a  peculiar  cell  form,  Nissl's 
Stdhchenzellen  or  rod-like  cells,  is  uniformly  present.  [Alz- 
heimer thinks  they  develop  from  some  of  the  elements  of  the 
blood  vessels.     Mott  thinks  them  collapsed  capillaries.] 

Ganglion  Cell  Changes. — (a)  These  are  extremely  diverse  and 
widespread,  but  are  not  of  themselves  pathognomonic  of  paresis. 
Practically  no  case  of  paresis  is  known  that  does  not  show  gan- 
glion cell  changes  of  some  character. 

(&)  These  changes  embrace  practically  all  of  the  forms  of 
ganglion-cell  alteration  that  have  been  described.  Many  of  these 
are  extreme  in  grade,  as  shown  by  the  rapid  degeneration,  and 
the  necrobiotic  changes  that  are  present. 

(c)  A  great  number  of  ganglion  cells  are  completely  destroyed 
in  the  advanced  cases. 

{d)  Not  only  are  the  ganglion  cells  altered,  but  in  all  proba- 
bility the  finer  nerve  structures  which  lie  between  the  ends  of  the 
sheath-covered  axis  cylinders  and  the  ganglion  cells  are  distinctly 
involved. 

{e)  In  the  majority  of  advanced  paretics,  the  arrangement  of 
the  ganglion-cell  groups  is  modified,  i.  e.,  the  cell  architecture  of 
the  cortex  is  changed  in  lesser  or  greater  degree. 


150  OUTLINES  OF  PSYCHIATRY. 

Changes  in  Axis  Cylinders. — These  undergo  early  degeneration 
in  many  cases.  Present  technical  methods  do  not  permit  the 
demonstration  of  these  alterations  in  the  very  early  stages,  but 
in  the  advanced  cases,  the  degeneration  of  the  axis  cylinders  is 
very  marked,  such  breaking  down  either  being  localized  or  involv- 
ing the  entire  cortex. 

Changes  in  Glia. — (a)  There  is  marked  growth  in  the  con- 
nective tissue  elements.  In  the  advanced  cases  such  increase  of 
glia  elements  forms  almost  a  felt  of  tissue  in  the  cortex. 

(&)  The  major  portion  of  the  new  glia  is  found  in  the  outer 
layers  of  the  cortex,  making  it  stronger,  as  it  were.  The  thick- 
ening due  to  new  glia  elements  is  particularly  noticeable  about 
the  blood  vessels. 

Although  the  cortex  is  most  prominently  afifeoted,  other  por- 
tions of  the  brain,  together  with  the  spinal  cord,  are  usually 
involved,  while  the  general  disturbance  of  nutrition  is  shown  in 
diseased  and  degenerated  conditions  of  various  other  organs,  par- 
ticularly the  kidneys. 

While  the  pathology  of  paresis  discloses  both  inflammatory  and 
degenerative  lesions,  it  is  still  a  mooted  point  which  process — 
inflammation  or  degeneration — should  be  considered  as  primary. 

Interpretation  of  the  Paretic  Psychosis. 

The  interpretation  of  the  mental  symptoms  of  paresis  may 
advantageously  be  approached  from  two  angles.  In  the  first  place 
from  a  consideration  of  the  personality  make-up  previous  to  the 
onset  of  the  disease  process.  The  disorder  of  mind  must  be  a 
disorder  of  that  which  existed  before  and  therefore  the  character 
of  the  mental  symptoms  is  directly  dependent  upon  the  type  of 
individual.  Osnato®  believes  that  it  is  the  abnormal  types  of 
personality  that  are  more  apt  to  develop  paresis  following  luetic 
infection.  In  the  second  place  as  an  expression  of  organ  inferi- 
ority (cortex)  in  harmony  with  the  conception  of  Adler^"  and 
also  with  the  conclusions  of  Bolton." 

^  Osnato,  Michael :  Personality  in  Paresis.  Jour.  Amer.  Med.  Assn., 
Feb.  1 6,  1918. 

i<>  Adler,  Alfred :  Study  of  Organ  Inferiority  and  its  Psychical  Compen- 
sation.   Nerv.  and  Mental  Dis.  Monograph  Series,  No.  24. 

^1  Bolton,  Joseph  Shaw:  The  Brain  in  Health  and  Disease,  London,  Ed- 
ward Arnold,  1914. 


PARESIS.  151 

The  grandiose  type  of  paretic  symptom  I  believe  falls  quite  in 
line,  in  its  interpretation,  with  this  concept  of  organ  (cortex) 
inferiority.  The  destructive  leutic  process  produces  as  it  ad- 
vances an  ever  increasing  mental  inefficiency  which  is  compensated 
for  in  the  only  possible  way  because  of  its  organic  basis,  namely 
by  phantasy.  The  patient  begins  to  build  up  delusions  of  power 
to  compensate  for  the  progressing  weakness  and  these  delusions 
increase  in  improbability  as  the  destructive  process  results  in 
increased  mental  weakness.  This  pyramiding  of  the  delusions  of 
grandeur  (the  patient  is  not  only  worth  hundreds  of  thousands, 
but  millions,  trillions,  quadrillions,  etc.,  finally  having  to  invent 
words  to  express  the  size  of  his  fortune)  goes  on  and  on  in  a 
vain  effort  to  overtake  the  results  of  cortical  (mental)  destruc- 
tion. Real  inefficiency  is  compensated  by  an  effort  to  think  him- 
self efficient,  efficiency  is  sought  to  be  brought  about  by  thinking 
hard  enough  that  it  is  really  so,  results  are  sought  by  thinking  of 
them  as  attained — ^the  "  all-power  fulness  of  thought." 

Diagnosis. — One  of  the  recent  aids  to  the  diagnosis  of  paresis 
is  by  the  method  of  examination  of  the  spinal  fluid.  A  well- 
marked  lymphocytosis  will  serve  to  differentiate  this  disease  from 
the  so-called  vesanias  or  functional  psychoses  but  not  of  course 
from  other  conditions  in  which  the  meninges  are  seriously 
involved. 

The  cellular  content  of  the  cerebrospinal  fluid  is  similar  to  that 
found  in  cerebrospinal  syphilis  except  that  the  phagocytic  cells 
(phagocytes,  macrophages,  Kornchen  cells)  are  less  numerous  and 
there  are  found  in  addition  from  one  to  six  per  cent,  of  plasma 
cells. 

The  Wassermann  test  will  be  positive  in  both  blood  serum  and 
cerebrospinal  fluid  and  the  Noguchi  test  will  show  an  increase  of 
globulin. 

The  principal  diseases  for  which  paresis  may  be  mistaken  at 
the  clinical  level,  especially  in  the  early  stages,  are  tabes,  acquired 
neurasthenia,  alcoholism,  brain  tumor,  cerebral  syphilis,  dissemi- 
nated sclerosis,  the  functional  psychoses,  epilepsy,  and  arterio- 
sclerotic dementia. 

The  principles  of  its  differentiation  from  the  various  psychoses 
have  been  already  indicated.  The  presence  of  the  underlying 
dementia  in  a  person  of  middle  age  should  make  us  at  once  sus- 


152  OUTLINES   OF   PSYCHIATRY. 

picious  and  if  to  this  condition  the  physical  signs  can  be  added  a 
diagnosis  can  with  certainty  be  made.  The  most  important  dif- 
ferentia, however,  are  the  serological  findings,  viz.,  the  presence 
of  the  four  reactions. 

From  tabes  dorsalis  the  differentiation  is  not  so  easy,  and  in 
fact  there  remain  a  few  cases  where  it  is  impossible,  and  we 
must  wait  for  the  development  of  further  symptoms.  This  is 
due  to  the  fact  that  in  their  early  stages  the  physical  signs  may 
be  identical  in  the  two  diseases.  When,  however,  we  observe 
a  case  in  which  the  tabetic  signs  are  somewhat  atypical  with, 
for  instance,  preservation  of  knee-jerks  or  marked  ataxia  of  the 
arms,  we  may  be  suspicious  of  paresis  and  if  with  this  condition 
we  find  associated  evidences  of  mental  disturbance  a  tentative 
diagnosis  is  in  order. 

In  differentiating  paresis  from  acquired  neurasthenia  the  gen- 
eral mental  attitude  of  the  patient  is  of  great  significance.  Whereas 
the  neurasthenic  is  given  to  exaggerating  his  ills,  to  constantly 
complaining  of  his  aches  and  pains,  and  keeps  close  observation 
of  every  change  of  symptoms,  the  paretic  is  usually  indifferent  or 
may  on  the  contrary  consult  a  physician  under  protest  and  in  the 
firm  belief  of  the  uselessness  of  so  doing  as  he  feels  so  well. 
This  is  not  invariable,  as  I  have  seen  paretics  well  advanced  in 
the  disease  who  were  much  concerned  over  their  condition.  The 
contrary  state  of  mind,  as  illustrated  by  one  of  my  patients,  is 
more  common.  On  her  admission  I  discovered  a  well-marked 
hemiplegia  which  she  actually  knew  nothing  of  until  I  called  her 
attention  to  it.  In  addition  to  this,  there  is  in  neurasthenia  no 
dementia,  no  disturbance  of  speech  or  writing,  no  history  of  seiz- 
ures, the  tendon  reflexes  are  equal  and  not  aboHshed,  the  pupils 
equal,  respond  to  light  and  accommodation  and  are  more  apt  to 
be  dilated,  while  in  paresis  they  are  frequently  unequal  and  often 
very  much  contracted.  The  laboratory  findings  will  of  course  be 
conclusive. 

From  alcoholism  the  diagnosis  is  often  not  so  easy.  The 
deterioration  of  the  chronic  alcoholic  has  much  in  common  with 
the  dementia  of  paresis.  Here  again  we  must  turn  to  the  phys- 
ical signs  and  note  carefully  the  historic  facts.  Following  a  long 
debauch,  however,  symptoms  may  arise,  which,  in  the  absence  of 
a  history,  would  warrant  a  diagnosis  of  paresis — the  so-called 


PARESIS.  I  5  3 

alcoholic  pseudo-paresis.  These  symptoms  disappear,  though,  in 
a  remarkable  manner  when  the  alcohol  is  withdrawn.  The  sero- 
logical findings  are  diagnostic. 

In  toxic  conditions  generally  sluggish  reaction  of  the  pupil  to 
light  is  not  uncommon,  while  Argyll-Robertson  pupil  may  prob- 
ably occur  for  a  temporary  period. 

Symptoms  occasionally  develop  in  the  course  of  brain  tumor 
which  closely  resemble  paresis.  The  diagnosis  must  be  made  on 
the  preeminently  focal  character  of  the  physical  signs  in  the 
former  disease,  although  paresis  often  presents  very  marked  focal 
signs,  especially  early  in  its  course.  The  serological  findings  will 
usually  make  this  situation  clear. 

From  disseminated  sclerosi  the  differentiation  is  sometimes 
difficult.  The  combination  of  intention  tremor,  nystagmus,  scan- 
ning speech  and  spasticity  will,  however,  usually  leave  little  room 
for  doubt,  although  some  of  these  cases  do  ultimately  develop 
typical  signs  of  paresis. 

From  vascular  cerebrospinal  syphilis  the  diagnosis  is  again 
quite  difficult.  If  the  lesion  is  a  gummatous  meningitis  the  signs 
are  rather  of  multiple  lesions  than  a  diffuse  process.  If,  on  the 
other  hand,  the  disease  aflfects  principally  the  vessels,  with  result- 
ing endarteritis  obliterans,  thrombosis  and  softening,  the  symp- 
toms are  focal  and  convulsions  developing  afterward  constitute  a 
true  post-apoplectic  epilepsy.  Disturbances  of  speech  either  are 
not  present,  or,  if  they  are,  do  not  partake  of  the  nature  of  a 
paretic  disorder  but  are  true  aphasias,  due  to  focal  lesions.  Pal- 
sies, if  present,  are  permanent  and  nocturnal  headaches  common. 
The  age  of  onset  should  be  considered.  Under  thirty  syphilis  is 
more  commonly  found  to  be  the  cause  of  cerebral  manifestations 
than  paresis.  It  must  not  be  forgotten  that  sluggish  reaction  to 
light  and  even  Argyll-Robertson  pupil  may  be  found  in  cerebral 
syphilis. 

The  cerebrospinal  fluid  should  be  examined.  It  will  show  an 
increase  in  the  cellular  elements  except  occasionally  if  active  anti- 
syphilitic  treatment  has  been  pursued  for  some  time.  The  dififer- 
ential  will  show  an  increase  in  lymphocytes  plus  phagocytes, 
macrophages,  endothelial  cells,  and  occasionally  Kornchenzellen. 

Plaut^^  has  claimed  a  most  important  differential  sign.     He 

12  Plaut,  F. :  Die  luetischen  Geistesstorunge,  Centralbl.  f .  Nervenheil- 
kunde  u.  Psychiatric,  Sept.  i,  and  IS,  1909. 


154  OUTLINES   OF   PSYCHIATRY. 

claims  that  only  in  the  metasyphilitic  diseases — tabes  and  paresis — 
will  the  spinal  fluid  give  a  positive  Wassermann  reaction,  while 
the  blood  serum  reacts  positively  in  all  cases  of  syphilis.  Experi- 
ence has  not  borne  out  this  claim.  Here  the  Lange  colloidal  gold 
test  is  of  great  help,  the  test  showing  either  in  the  syphilitic  or  the 
paretic  zone  as  the  case  may  be.  A  typical  paretic  curve  would 
be  5555432000,  a  typical  luetic  curve  would  be  3321 122200. 

From  the  so-called  functional  psychoses  a  differential  diagnosis 
may  be  difficult  in  the  early  stages,  especially  if  there  are  marked 
emotional  disorders  or  paranoid  delusions.  The  presence  of  the 
physical  signs  of  paresis  associated  with  symptoms  of  dementia 
and  the  cytological  examination  of  the  cerebrospinal  fluid  will 
usually  clear  up  the  difficulty. 

In  the  early  stages,  in  those  cases  that  have  been  ushered  in  by 
a  paretic  seizure,  epilepsy  may  be  suspected.  The  absence  of  the 
history  of  epilepsy  should  suggest  paresis. 

The  diffusion  of  the  destructive  lesions  in  arteriosclerotic 
dementia  is  not  infrequently  responsible  for  a  picture  closely 
resembling  paresis.  This  condition  occurs  much  later  in  life, 
usually  after  the  sixtieth  year;  there  are  evidences  of  advanced 
vascular  disease,  and  the  characteristic  senile  disorder  of  memory 
is  present. 

An  examination  of  the  cerebrospinal  fluid  will  seldom  show  any 
increase  in  the  cellular  constituents  and  if  there  is  an  increase  it 
will  be  slight,  while  the  character  of  the  cells  is  practically  normal. 
The  Wassermann  test  will  be  negative. 

It  must  not  be  lost  sight  of  that  syphilis  may  complicate  any 
of  these  conditions  and  give  the  characteristic  laboratory  findings. 

Course  and  Prognosis. — The  disease  may  be  said  to  be  abso- 
lutely fatal,  although  an  occasional  alleged  cure  is  reported.  Re- 
missions quite  frequently  occur,  so  that  the  patient  may  be  well 
enough  to  leave  the  hospital  and  remain  away  for  weeks  or  even 
months.  The  fact  that  remissions  occur  should  never  be  for- 
gotten in  giving  a  prognosis  to  the  relatives.  The  acute  forms  of 
the  disease  are  rapidly  fatal,  the  majority  die  in  from  eighteen 
months  to  three  years,  while  in  a  certain  few  cases  the  disease 
process  is  very  slow  and  may  occupy  many  years. 

Death  usually  occurs  from  some  intercurrent  affection,  pneu- 
monia,  cystitis,  terminal  infection,   or   from  the   disease  itself. 


PARESIS,  155 

which  leads  to  an  extreme  degree  of  emaciation  and  exhaustion. 

Treatment. — ^This  disease  is  from  the  first  preeminently  a  dis- 
ease for  institution  care.  The  patient  is  absolutely  unable  to  care 
for  himself  and  in  the  great  majority  of  instances  the  friends  are 
equally  unable  to  care  for  him.  As  soon  as  the  diagnosis  is  made 
steps  should  be  taken  looking  towards  the  appointment  of  a  com- 
mittee of  his  person  and  property  or  otherwise  guarding  his  busi- 
ness interests,  which  upon  investigation  will  show  almost  without 
failure  evidences  of  poor  management,  the  result  of  early  mani- 
festations of  the  dementia. 

While  antisyphilitic  treatment  has  as  yet  yielded  no  brilliant 
results  in  the  treatment  of  paresis  there  is  always  a  certain  justifi- 
cation for  attacking  the  problem  energetically.  In  paresis  vascular 
alterations  often  exist  side  by  side  with  parenchymatous  changes. 
These  vascular  changes  are  materially,  often  much,  helped  by 
antisyphilitic  therapy. 

Tube  feeding  may  have  to  be  early  resorted  to  because  of  the 
development  of  dysphagia  and  the  consequent  danger  of  choking. 
The  most  scrupulous  care  should  be  taken  to  prevent  the  develop- 
ment of  bed-sores,  as  they  are  practically  impossible  to  heal  and 
do  much  towards  hastening  the  fatal  termination. 


CHAPTER   XI. 

Dementia  Precox. 

General  Characteristics. — Dementia  precox  is  a  psychosis  es- 
sentially of  the  period  of  puberty  and  adolescence,  characterized 
by  a  mental  deterioration  tending  to  progress,  though  frequently 
interrupted  by  remissions. 

There  has  been  a  great  deal  of  objection  to  the  name  "  Dementia 
Precox,"  because  of  the  fact  that  some  cases  develop  considerably 
later  in  life  than  the  adolescent  period.  For  those  who  are 
anxious  that  the  name  should  be  significant  of  the  thing  named, 
it  might  be  satisfactory  to  think  of  dementia  precox  not  as  a  psy- 
chosis developing  early  in  life,  and  therefore  precocious,  but  as 
a  psychosis  in  which  the  factor  of  deterioration  appears  early,  in 
other  words,  a  psychosis  in  which  the  deterioration  is  the  pre- 
cocious symptom,  rather  than  an  individual  in  whom  the  psychosis 
is  precocious.  Because  of  the  further  fact  that  the  so-called 
dementia  is  in  many  instances  at  least  more  apparent  than  real, 
and  because  a  careful  analysis  of  the  psychology  of  these  cases 
shows  that  the  outwardly  bizarre  and  erratic,  and  often  silly 
symptoms  have  in  reality  a  foundation  which  is  rationally  explain- 
able, Bleuler  has  suggested  the  name  "  Schizophrenia,"  which 
indicates,  as  will  be  seen  later,  a  splitting  of  the  psyche,  which  is 
considered  by  him  to  be  the  real  fundamental  symptom  of  the 
disease. 

Etiology. — Dementia  precox  is  essentially  a  disease,  as  stated, 
of  the  period  of  puberty  and  adolescence.  Heredity  plays  an  un- 
certain role  in  its  etiology  but  the  disease  seems  to  afiford  evidence 
of  Mendehan  recessive  factors.  The  future  patient  might  be 
expected  to  be  rather  dull  in  his  early  youth  and  show  difficulty 
in  getting  on  with  his  studies.  While  this  is  not  infrequently  the 
case,  still  cases  often  occur  in  young  persons,  not  only  of  appar- 
ently usual  mental  power,  but  of  brilliant,  perhaps  precociously 
brilliant  faculties.  This  has  thrown  some  doubt  on  the  hereditary 
basis  of  the  disease,  especially  as  sometimes  no  serious  taint  can 

156 


DEMENTIA  PRECOX.  I  57 

be  found  in  the  antecedents.  In  this  particular  form  of  mental 
alienation,  I  think  it  is,  however,  especially  important  to  search 
for  other  than  distinctly  mental  disease  in  the  ancestors. 

WoLFSOHN^  has  made  a  study  of  the  material  of  the  Burgholzi 
Asylum  at  Zurich  with  a  view  to  the  determination  of  the  fre- 
quency of  the  hereditary  factor.  Of  2215  admissions  there  were 
647  cases  of  dementia  precox.  About  90  per  cent,  of  these  showed 
hereditary  taint :  of  four  hereditary  factors  insanity  was  the  most 
frequent  (about  64  per  cent.),  followed  by  nervous  diseases, 
alcoholism,  and  other  forms  of  hereditary  taint:  heredity  was 
combined  in  about  34  per  cent.  The  most  frequent  combinations 
were  insanity  and  alcoholism,  and  insanity  and  nervous  disease: 
the  distinct  influence  of  heredity  could  not  be  proven  in  the  cases 
in  which  the  taint  was  alcoholism,  nervous  disease,  and  other 
forms:  the  influence  of  the  taint  has  no  striking  effect  on  the 
character  of  the  first  symptoms :  the  catatonic  form  is  the  most 
and  the  paranoid  the  least  affected  by  the  taint  of  insanity. 

Every  individual  born  into  the  world  has,  if  it  could  be  deter- 
mined, a  definite  potentiality  for  development.  The  force  of  the 
impetus  which  starts  it  on  its  path  is  sufficient  to  carry  it  a  certain 
definite  distance.  The  predetermined  goal,  in  each  case,  will  be 
reached  if  no  accident  intervenes  to  prevent.  In  the  subject  of 
this  disease  the  original  impetus  has  been  weak,  only  sufficient  to 
carry  them  a  short  way  and  when  its  force  is  spent  development 
stops  and  the  retrograde  process  is  hastened,  or  perhaps  imme- 
diately initiated  by  some  special  physical  or  mental  stress  occur- 
ring at  the  critical  point  of  puberty  and  adolescent  evolution.  As 
the  French  have  it,  these  patients  are  "  stranded  on  the  rock  of 
puberty." 

Aside  from  this  class  of  causes,  direct  heredity  is  frequently 
in  evidence,  and  families  with  several  cases  of  dementia  precox  in 
them,  just  as  similar  conditions  in  manic-depressive  psychosis  are 
found. 

Of  exciting  causes  it  would  seem  that  severe  shocks,  both  phys- 
ical and  mental,  as,  for  example,  severe  hemorrhages,  infections — 
often  puerperal — fright,  and  that  train  of  emotional  disturbances 
following  seduction  and  desertion  are  found.     Particular  stress 

iWolfsohn,  Ryssa:  Die  Hereditat  bei  Dementia  prsecox,  Allg.  Zeitschr. 
f.  Psych.,  Bd.  64  (1907).  Heft  2  and  3. 


158  OUTLINES   OF   PSYCHIATRY, 

should  be  laid  upon  psychogenic  factors  in  the  etiology  and  they 
should  always  be  sought  for. 

Recently  a  great  deal  has  been  said  about  a  possible  toxic  factor 
as  being  responsible  for  the  disease  and  this  toxic  factor  has  been 
supposed  to  have  its  origin  in  some  of  the  glands  after  the  analogy 
of  the  toxin  in  thyroidism — probably  some  internal  secretion  of 
the  testicle  or  ovary,  as  the  disease  is  so  closely  associated  with 
the  changes  incident  to  puberty.  Then,  again,  the  changes  of 
metabolism  in  this  disease  are  quite  pronounced  and  are  thought 
to  find  their  explanation  in  a  toxemia.^ 

The  latest  tendency  is  to  give  greater  prominence  to  the  mental 
factors  as  having  etiological  importance.  Jung^  by  his  analyses 
has  especially  called  attention  to  the  buried  complexes  with  result- 
ing symptoms,  while  Meyer*  considers  the  condition  more  from 
a  biological  standpoint  as  being  the  result  of  continued  inability  to 
adjust  with  the  development  of  unhealthy  biological  reactions. 
Recent  studies  would  indicate  that  these  difficulties  arise  in  people 
of  peculiar  character  make-up — more  particularly  in  those  who 
have  what  is  termed  a  "  shut-in  "  character.  These  persons  do 
not  meet  difficulties  openly  and  frankly,  they  are  inclined  to 
be  seclusive,  not  to  make  friends,  to  have  no  one  to  whom  they 
are  close  and  with  whom  they  can  talk  over  things.  They  do  not 
come  into  natural  and  free  relation  with  the  realities,  are  apt  to 
be  prudes,  over-scrupulous,  and  exhibit  a  sentimental  religiosity. 
In  short  the  psychogenic  features  of  the  disease  are  conditioned 
by  the  mental  conflict. 

General  S5miptomatology. — Mental:  In  considering  the  mental 
symptoms  of  dementia  precox  Stransky^  very  happily  calls  atten- 
tion to  the  very  different  impression  this  disorder  makes  on  one 
than  do  such  conditions  as  mania,  melancholia,  paranoia  and 
amentia  (confusion).  These  latter  disorders  seem  to  us  to  be 
due  to  the  deviation  of  normal  mental  processes  either  to  the 

2  Jelliffe :  Dementia  Precox  and  the  Vegetative  Nervous  System,  N. 
Y.  Med.  Jour.,  1917. 

^  Jung,  C.  G. :  The  Psychology  of  Dementia  Praecox,  Nerv.  and  Ment. 
Dis.  Monog.  Series,  No.  3. 

*  Meyer,  Adolf:  Fundamental  Conceptions  of  Dementia  Praecox,  Brit. 
Med.  Jour.,  Sept.  29,  1906. 

^  Stransky,  Erwin :  t)ber  die  Dementia  Prsecox,  Streifzuge  durch  KHnik 
und  Psychopathologie.     Verlag  von  J.  F.  Bergmann,  Wiesbaden,  1909. 


DEMENTIA   PRECOX.  I  59 

positive  or  negative  side;  we  can  put  ourselves,  as  it  were,  in  the 
position  of  the  patient,  can  feel  his  feelings  in  miniature.  The 
differences  are  merely  differences  of  degree,  of  more  or  less. 
With  dementia  precox,  however,  the  effect  is  quite  different.  The 
awkward,  constrained  attitude  of  these  patients  makes  us  feel 
quite  out  of  touch  with  them,  they  seem  unnatural,  their  acts  "  un- 
psychological,"  to  coin  an  expression. 

This  fundamental  difference  in  the  impression  created  in  us  by 
the  dementia  precox  patient  from  that  produced  by  other  types  of 
mental  disorder  Stransky  traces  to  what  he  believes  to  be  the 
basic  factor  in  the  symptomatology — intrapsychic  ataxia.  By  this 
term  he  means  a  disturbance  of  coordination  between  the  intel- 
lectual attributes  of  the  whole  psyche  and  the  affective  attributes, 
or  as  he  calls  them  respectively  the  noopsyche  and  the  thymo- 
psyche.  Intrapsychic  ataxia  might  then  be  called  more  specifi- 
cally a  no o-thymo psychic  ataxia. 

The  recognition  of  this  ataxia,  the  separation  of  intellectual  and 
emotional  reactions,  has  led  some  to  prefer  the  name  schizo- 
phrenia to  dementia  precox. 

This  intrapsychic  disturbance  of  coordination  leads  to  a  defect, 
the  signs  of  which  are  much  more  marked  in  the  emotional  sphere 
than  in  the  intellectual  sphere. 

Inasmuch  as  this  disturbance  of  coordination  is  the  most  im- 
portant expression  of  dementia  precox,  according  to  Stransky,  it 
will  be  worth  while  to  go  somewhat  into  the  details  of  his  descrip- 
tion of  it. 

The  coordination  disturbance  may  manifest  itself  in  different 
ways  and  in  different  degrees.  The  simplest  way  is  by  a  lack  of 
harmony  between  the  expression  of  the  affect  and  the  idea  con^ 
tent  of  thought.  For  example  the  patient  cries  when  he  should 
be  glad,  or  vice  versa,  though  much  commoner  than  this  con- 
trasted reaction  is  an  affective  reaction  which  is  inadequate — 
the  patient  merely  simpers  or  smiles  when  the  facts  would  war- 
rant sadness  or  hearty  laughter.  We  come  across  anger  from 
wholly  indifferent  causes ;  fear,  timidity,  shyness  appear  without 
any  apparent  reason ;  familiarity,  obtusiveness,  eroticism  occur, 
displaced,  perhaps  in  the  same  situations  in  which  there  was 
formerly  embarrassment,  shyness,  coldness.  Quite  commonly  a 
certain  state  of  feeling  dominates  all  conditions  of  consciousness. 


l60  OUTLINES  OF   PSYCHIATRY. 

a  certain  stupidity  and  apathy,  a  surprising  poverty  of  affect, 
which  is  in  strong  contrast  to  the  clearness  which  the  patient  may 
demonstrate.  Cold  and  passive,  without  so  much  as  moving  an 
eye  lash,  without  any  spontaneous  reaction,  without  expressing 
a  wish,  he  is  oriented  to  time  and  place  and  person,  is  conversant 
with  everything  going  on  about  him,  shows  good  school  knowl- 
edge, his  memory  is  faultless,  shows  up  well  in  an  examination 
of  his  intelligence,  and  denies  feeling  sick.  However,  he  shows 
no  longing  after  freedom,  or  feeling  of  sadness  at  his  position; 
these  all  appear  extinguished  in  him.  This  coldness  produces  an 
unnatural  impression.  One  gets  the  impression  of  the  dream  state 
in  epilepsy,  the  mental  state  of  which  has  a  certain  symptomatic 
relationship  with  many  forms  of  dementia  precox. 

The  lack  of  conformity  of  the  emotional  reaction  and  the  idea 
content  is  shown  not  only  with  reference  to  a  given  time  but  in 
relations  of  succession.  Moods  and  affects  change  in  all  possible 
ways  without  visible  inner  or  outside  causes.  Here  we  see  the 
same  ataxic  tendency.  The  April-weather  behavior  of  the  affects 
and  moods  suggests  the  relationship  with  hysteria. 

This  condition  of  intrapsychic  ataxia  does  exist  but  Bleuler* 
has  shown  quite  conclusively,  I  think,  that  it  is  only  one  expression 
of  what  he  calls  a  splitting  of  the  psyche.  The  characteristic 
associations  of  precox  all  show  this  tendency  toward  splitting, 
while  negativism  is  a  demonstration  of  it.'^  In  negativism  two 
entirely  contrary  streams  of  thought  flow  side  by  side  without 
being  able  to  mix,  with  no  possibility  of  synthesis,  each  producing 
its  characteristic  reactions.  Thus  a  woman  loves  her  husband 
for  some  qualities  and  hates  him  for  others.  There  is  no  compro- 
mise and  first  one  and  then  the  other  feeling  is  in  the  ascendant. 
We  will  see  the  importance  of  this  conception  when  we  come  to 
consider  the  nature  of  the  dementia. 

It  is  this  fundamental  disturbance  in  coordination  that  gives 
rise  to  the  commonly  described  symptoms  of  failure  of  voluntary 
attention  and  the  lack  of  interest  which  these  patients  show  both 
in  themselves  and  their  surroundings.     They  care  little  if  at  all 

^  Bleuler :  Dementia  Praecox  oder  Gruppe  der  Schizaphrenien.  Pub.  by 
Deuticke,  Leipzig  und  Wien,  191 1. 

^Bleuler:  The  Theory  of  Schizophrenic  Negativism  (Eng.  trans,  by 
White),  Monograph  Series,  No.  11. 


DEMENTIA   PRECOX.  l6l 

about  what  goes  on  about  them,  and  although  confined  in  an  insti- 
tution, express  themselves  as  satisfied  with  their  condition  and 
have  no  desire  to  leave.  They  sit  idly  about,  giving  no  heed  to 
what  goes  on  about  them,  are  unable  to  apply  themselves  to  any 
sort  of  work  or  even  reading,  and  when  questioned  may  even  pay 
so  little  attention  as  not  to  understand  what  is  said  to  them,  so 
that  the  question  has  to  be  repeated. 

From  this  lack  of  attention  things  in  the  environment  are  often 
not  perceived  at  all,  but  when  they  are  perceived  they  are  under- 
stood quite  fully,  and  we  usually  find  these  patients  are  well 
oriented  in  all  respects,  temporal,  spatial  and  personal,  and  show 
no  evidences  of  clouding  of  cotisciousness. 

In  the  same  way  also  arises  the  so-called  emotional  deteriora- 
tion which  they  exhibit.  It  is  this  symptom  which  is  largely 
responsible  for  their  indifference  and  lack  of  interest  already  men- 
tioned. The  expressions  of  joy  or  sorrow,  if  they  occur  at  all, 
are  shallow  and  of  short  duration.  A  death,  a  birth,  a  marriage, 
the  visit  of  a  long  absent  relative,  are  all  apprehended  with  the 
same  lack  of  emotional  expression.  No  matter  how  much  pleasure 
or  pain  the  event  might  be  supposed  to  give,  or  would  give  in  a 
normal  person,  the  patient  receives  it  with  indifference,  without 
surprise,  without  an  expression  of  interest  often,  in  the  most 
matter  of  fact  sort  of  way,  as  if  such  things  were  occurring 
hourly. 

A  similar  condition  of  affairs  is  found  in  the  intellectual  domain. 
The  ideas,  the  content  of  thought,  show  a  shallowness  indicating 
an  intellectual  enfeeblement.  Aside  from  the  fact  that  the  fan- 
tastic, unusual,  bizarre  character  of  the  delusions  indicates  the 
dilapidated  groundwork  on  which  they  are  founded,  the  patients 
make  little  or  no  effort  to  support  their  false  beliefs,  show  abso- 
lutely no  insight  into  their  condition,  and  make  the  most  mani- 
festly absurd  statements  often  in  the  midst  of  a  fairly  coherent 
conversation  without  at  all  appreciating  the  incongruity.  Thus, 
one  patient  was  able  to  answer  questions  bearing  on  history  quite 
well,  but  when  asked  for  some  explanation  as  to  his  belief  that  the 
electric  lights  were  burning  holes  in  him  replied  by  saying.  "  They 
are  pretty  good  people  anyway."  The  same  patient  had  the  delu- 
sion that  he  had  no  eyes  or  hands.  Usually  when  questioned 
about  such  evident  absurdities  no  explanation  is  vouchsafed  and 


1 62  OUTLINES   OF   PSYCHIATRY. 

the  patient  retires  behind  the  reply,  "  I  don't  know."  The  dilapi- 
dation of  thought  becomes  more  and  more  manifest  as  deteriora- 
tion progresses,  leading  finally  in  its  expression  to  almost  com- 
plete incoherence,  as  shown  in  the  following  example. 

"  Oh,  yes,  indeed,  that  the  weather  and  condition  of  such  become  rainy 
and  people  dying,  and  the  worms  eat  the  bodies  up  and  take  them  from 
their  coffins,  they  would  not  allow  you  to  disclose  the  bodies,  because  the 
overflow  of  saliva  causes  the  disease  by  which  people  cannot  exist.  Well, 
I  am  the  only  King  over  in  Ireland.  I  do  not  know  where  he  has  gone. 
They  wanted  to  put  me  in  a  wash-tub  and  everything  else.  They  do  not 
know  what  I  am,  do  you  see  They  come  into  a  saloon,  but  they  will  not 
give  you  anything  to  drink.  I  was  the  bartender  there.  I  am  a  stranger. 
People  kill  them,  but  they  come  to  life  again.  They  take  the  position  of 
strangers  when  they  leave  their  happy  homes,  but  I  do  not  understand 
how  they  could  kill  a  woman  outright.  What  right  have  you  got  to  take 
a  stranger  when  they  are  in  their  rightful  homes?  This  is  the  post  of  duty 
where  men  of  enlistment  return  to  their  happy  homes.  This  is  the  post  of 
duty  to  enter  not.  They  must  be  prisoners.  They  do  not  get  out  of  sight. 
Dr.  Hogan  is  a  doctor  for  the  purpose  of  curing  people ;  also  Dr.  Burns ; 
where  they  are  going  I  know  not.  Well,  I  tell  you,  doctor,  I  suffered 
terribly  this  winter,  also  on  post  of  duty.  I  do  not  know  anything  at  all 
about  it,  but  there  is  an  illustration  there.  I  cannot  blame  the  band  while 
at  school  about  their  music.  That  thermometer  there  is  to  tell  whether 
you  live  or  die,  and  it  becomes  such  a  dangerous  position  that  the  enemies 
approaching  at  this  post  of  duty,  I  cannot  do  it  with  the  light.  The  man 
escaped.  He  is  living  at  his  home  in  Binghamton,  N.  Y.  Where  I  know 
not.  I  know  that  his  name  is  Irish.  They  will  not  take  him  to  his  rightful 
home  in  the  condition  of  such  by  which  he  has  no  means  of  support  by 
attending  bar.  I  was  kidnapped  upon  the  ocean,  and  taking  en  route  to 
this  place  I  know  not.  Well,  as  I  was  going  to  tell  you,  I  am  the  enemy 
himself.  These  people  here  cannot  perform  an  operation.  They  do  not 
know  what  they  are.  Well,  do  you  know  me!  I  am  the  King  of  Ireland, 
and  also  of  all  countries  in  existence.  I  was  the  fellow  that  killed  the 
Queen.  I  do  not  know  who  she  was.  I  got  the  picture  of  him.  His  last 
name  was  Duffy.     I  cannot  get  in  communication  with  him." 

In  this  example  the  incoherence  reaches  a  very  high  degree,  the 
conversation  becomes  a  mere  "word  salad,"  in  which  it  is  only 
possible,  here  and  there,  to  pick  out  an  association,  and  that  only 
of  superficial  character. 

The  memory  is  usually  defective,  especially  for  recent  events, 
reminding  us  of  the  memory  defect  of  senescence.  This  defect, 
to  a  certain  extent,  is  undoubtedly  apparent  only  and  dependent 
upon  lack  of  perceptions  because  of  the  inability  to  fix  the  atten- 


DEMENTIA  PRECOX.  1 63" 

tion.  An  event  which  is  not  perceived  will,  of  course,  not  be 
remembered,  and  similarly  an  event  which  is  only  perceived  in  a 
desultory  manner  and  not  fully  comprehended  will  not  be  recalled 
at  its  true  value.  It  becomes  quite  difficult,  therefore,  to  differ- 
entiate the  elements  of  this  defect  and  tell  how  much  is  due  to  a 
disorder  of  memory  per  se.  Undoubtedly  a  certain  proportion  of 
it  is,  though,  and  this  defect  is  probably,  largely  at  least,  a  defect 
of  impressibility. 

Knowledge  acquired  before  the  disease  began,  however,  espe- 
cially therefore,  as  these  patients  are  already  quite  young,  knowl- 
edge acquired  in  school,  is  often  remembered  with  quite  remark- 
able accuracy.  Whole  tables  of  matter,  learned  by  rote,  can  be 
repeated,  and  often  this  ability  constitutes  a  striking  feature  of 
the  case  when  the  dementia  has  become  profound,  and  this  symp- 
tom is  perhaps  about  the  only  one  left  to  indicate  that  the  patient 
was  ever  possessed  of  normal  mental  faculties. 

Many  of  the  symptoms  of  dementia  precox  are  conditioned  by 
the  existence  of  submerged  complexes.  The  complex  does  not 
cause  the  disease  but  it  colors  the  symptoms.  The  limits  of  this 
work  forbid  more  than  a  mere  mention  of  the  most  important 
manifestations. 

The  patients  frequently  complain  that  their  thoughts  leave  them 
suddenly  when  they  try  to  explain  themselves  and  we  note  in  these 
cases,  often  in  the  midst  of  a  conversation,  a  sudden  pause  and 
then  a  difficulty  in  resuming  the  train  of  thought.  This  thought 
deprivation  we  have  learned  from  association  work  is  the  result 
of  strong  emotional  content — the  flow  of  thought  being  inhibited 
by  the  presence  of  strong  emotion.  We  have  seen,  for  example, 
how  the  reaction  time  is  lengthened  when  an  idea  is  struck  with 
strong  emotional  coloring.  The  patients  often  give  a  delusional 
explanation  to  these  experiences  and  claim  that  they  are  robbed 
of  their  thought  by  their  enemies. 

We  find  also  that  frequently  in  the  midst  of  a  perfectly  co- 
herent and  reasonable  conversation  a  perfectly  senseless  remark 
will  be  injected.  These  saltatory  associations  indicate  the  mo- 
mentary outcrop  of  a  complex  association. 

In  the  same  way  the  stereotypies,  particularly  the  speech  per- 
severations, center  about  the  complexes  and  the  neologisms  be- 
come complex  indicators.     Because  of  the  submergence  of  the 


164  OUTLINES   OF  PSYCHIATRY. 

complexes,  the  patient  having  no  comprehensive  knowledge  of 
their  existence,  questions  addressed  to  eliciting  an  explanation  of 
these  phenomena  produce  no  results.    The  patients  are  maccessible. 

The  general  symptoms  of  the  disease  that  are  common  to  all 
varieties  are,  as  might  be  expected,  the  symptoms  of  mental  de- 
terioration, of  decreased  mental  efficiency. 

Physical:  These  patients  often  emaciate  during  the  early  stages 
of  the  disease,  anorexia  and  insomnia  are  common,  circulatory 
disturbances,  rapid  cardiac  action,  and  cyanosis  of  the  extremities 
are  often  seen,  as  is  also  dermographia,  the  result  of  vaso-motor 
paralysis.  The  deep  reflexes  are  exaggerated  and  the  pupils  quite 
commonly  widely  dilated.  Epileptiform,  and  especially  hysteri- 
form,  attacks  are  quite  frequently  observed  in  the  early  stages. 

In  the  early  history  many  apparently  unimportant  symptoms 
may  be  found,  such  as  headaches,  vertigo,  etc.  Urstein*  calls 
particular  attention  to  the  occurrences  of  gastric  disturbances, 
often  periodically.  This  is  one  of  the  general  neurastheniform 
symptoms  one  frequently  finds  in  the  anamnesias.  It  would  seem 
as  if  these  patients  hardly  had  force  enough  to  live,  that  some 
set  of  organs  was  always  suffering,  there  was  not  enough  to  go 
round. 

Mode  of  Onset. — The  early  manifestations  of  dementia  precox 
often  go  unrecognized  for  a  long  time  and  are  diagnosed  as  other 
conditions.  It  must  be  realized  that  it  may  often  be  quite  impos- 
sible to  make  a  diagnosis  by  taking  a  cross  section  of  the  mental 
state  at  any  time,  particularly  in  the  prodromal  or  initial  stages. 
This  is  particularly  true  here  as  the  early  manifestations  may  be 
acute  and  transitory  episodes  which  clear  up  promptly.  It  is  only 
by  studying  the  life  history  of  the  individual  that  we  come  to 
realize  that  these  episodes  are  but  the  early  manifestations  of  a 
chronic  process,  the  tendency  of  which  is  toward  progressive  de- 
terioration. 

These  early  manifestations  may  take  the  form  of  the  various 
types  of  the  manic-depressive  psychoses,  psychasthenia,  neuras- 
thenia, hysteria,  hypochondria,  acute  confusion  and  paranoid 
states.  In  all  this  class  of  cases,  particularly  if  atypical,  a  search 
should  be  made  for  the  fundamental  symptoms  as  already  de- 

8  Urstein,  M. :  Die  Dementia  Praecox  und  Ihre  stellung  zum  Manisch- 
Depressiven  Irresein.     Berlin  und  Wien,  1909. 


DEMENTIA   PRECOX.  1 65 

scribed,  particularly  the  emotional  indifference  and  the  attention 
disorders. 

In  describing  the  varieties  of  dementia  precox  they  will  be  con- 
sidered under  five  heads :  ( i )  the  dementia  simplex,  or  heboido- 
phrenia  of  Kahlbaum;  (2)  Hebephrenia;  (3)  Catatonia;  (4) 
Paranoid  Forms;  (5)  Mixed  Forms. 

I.  Simple  Dementia  (Heboidophrenia). 

In  accordance  with  the  conception  of  dementia  precox  outlined 
above,  which  regards  it  as  primarily  a  deterioration  upon  which 
various  psychotic  symptoms  may  be  engrafted,  this  variety  would 
constitute  the  typical,  fundamental  form  of  the  disease,  showing 
the  development  of  the  deterioration  per  se,  with  few  if  any  of 
the  extraneous  symptoms  found  in  abundance  in  some  of  the 
other  forms. 

The  origin  of  this  variety  is  insidious,  and  it  may  be  quite  im- 
possible to  fix  its  date,  largely  because  at  first  the  beginning  symp- 
toms were  not  appreciated  at  their  true  value.  The  young  boy, 
or  girl,  as  the  case  may  be,  quite  commonly  was,  previous  to  the 
onset  of  symptoms,  getting  on  nicely  in  school,  perhaps  unusually 
well,  was  quite  a  favorite  with  the  other  pupils,  took  an  active  in- 
terest in  school  life,  and  was  going  on  with  the  young  people  of 
the  neighborhood,  being  in  every  way  considered  a  bright  and 
normal  child.  The  fire  may  have  burned  very  brightly  but  it  was 
built  of  straw. 

At  first  the  patient  begins  to  show  a  lack  of  interest  in  things, 
ceases  going  out  and  associates  less  and  less  with  other  children. 
There  is  a  general  listless,  apparently  lazy  and  tired-out  attitude 
towards  life  assumed,  lessons  are  neglected  and  not  learned,  and 
in  school  the  patient  shows  a  failing  ability  to  assimilate  new  facts 
— to  acquire  knowledge. 

This  state  of  affairs  is  associated  with  insomnia  and  often  head- 
ache, sometimes  hysteriform  attacks,  and  not  infrequently  is  mis- 
taken for  neurasthenia,  or,  if  the  patient  is  quite  inactive,  this 
inactivity  is  taken  to  be  an  expression  of  the  depression  of 
melancholia. 

Transitory  delusions  may  occur,  which  are  fully  expressed,  and 
fleeting  hallucinations  may  at  times  occupy  the  field.  These  mani- 
festations are  usually  disagreeable,  voices  are  heard  saying  dis- 


1 66  OUTLINES   OF   PSYCHIATRY, 

agreeable  or  insulting  things,  visions  of  the  devil  occur  and  the 
like. 

Not  infrequently  these  patients  show  themselves  to  be  quite 
irritable,  and  partly  as  a  result  there  may  occur  transitory  ex- 
citements. If,  in  addition,  peculiarities  of  conduct  and  strange 
habits  develop,  the  desire  to  be  alone,  some  mannerism,  or  slight 
evidences  of  muscular  tension  and  the  simpler  manifestations  of 
negativism,  the  close  relation  between  these  and  the  more  fre- 
quent and  more  fully  developed  varieties  is  shown. 

It  is  in  this  group  that  we  find  the  mild  and  abortive  forms  that 
being  arrested  give  one  the  impression  that  the  peculiarities  of  the 
individual  are  inherent  character  anomalies.  Not  a  few  crimi- 
nals, hoboes,  prostitutes,  pseudo-geniuses,  cranks,  and  eccentrics 
if  their  history  could  be  accurately  traced  would  show  an  episode 
of  distinct  precox  coloring  which  separated  a  period  of  relative 
efficiency  in  their  lives  from  a  following  period  of  relative  in- 
efficiency. 

A  study  of  this  class  of  cases  shows  quite  frequently  that  the 
patient's  resort  to  a  hobo  type  of  existence  has  been  the  result  of 
his  inability  to  adapt  himself  to  the  ordinarily  complex  conditions 
of  social  life,  in  other  words,  that  he  has  slipped  from  under  all 
responsibilities  and  all  conditions  which  involved  continuity  of 
effort  and  industry.  He  goes  from  one  position  to  another  unable 
to  fulfill  even  the  simpler  duties  because  of  his  lack  of  continuity 
and  interest.  Such  cases  will  show  the  history  of  a  mild  attack, 
with  perhaps  the  development  of  a  dilapidated  and  incoherent 
delusional  system  which  subsides  and  remains  dormant  when  the 
patient  gets  away  from  stress.  Such  patients,  when  they  find 
themselves  under  conditions  of  stress  that  they  cannot  escape 
from,  as  for  example,  following  enlistment  in  the  military  service, 
quite  frequently  break  down  and  have  to  be  sent  to  a  hospital. 

II.  Hebephrenia. 

This  form  of  dementia  precox  is  usually  of  more  abrupt  onset 
than  the  last,  although  here  we  may  also  find  that  the  prodromal 
period  extends  over  several  months,  during  which  time  the  patient 
suffers  from  insomnia,  headache,  anorexia,  and  perhaps  some  loss 
of  flesh. 

The  symptoms  of  the  onset  of  the  attack  are  quite  generally 


DEMENTIA  PRECOX.  1 6/ 

confusion  and  symptoms  of  depression  which  have  an  outward 
semblance  to  the  symptoms  of  a  depression.*  The  characteristic 
retardation  of  manic-depressive  psychosis  is,  however,  absent, 
and  hallucinations  and  delusions  occupy  a  much  more  prominent 
place  in  the  picture.  These  hallucinations  are  numerous  and  in- 
volve more  especially  the  auditory  and  visual  fields.  Both  hallu- 
cinations and  delusions  are  disagreeable.  Voices  are  heard  calling 
vile  names  and  accusing  the  patient  of  immoral  practices ;  delu- 
sions are  self-accusatory  and  in  harmony  with  the  depression,  the 
patient  thinks  he  is  lost  for  having  masturbated  and  the  like.  In 
this  condition  violent  attempts  at  suicide  are  not  infrequent  and 
only  go  to  add  force  to  the  diagnosis  of  melancholia  so  often  made 
at  this  stage  of  the  disease. 

After  the  active  symptoms  of  the  first  stages  are  passed  the 
underlying  and  fundamental  defect  becomes  more  apparent.  The 
hallucinations  are  fleeting,  the  delusions  not  firmly  fixed  but 
changeable  and  fantastic  or  silly  in  content,  though  often  with  a 
paranoid  tinge;  thus  one  patient  believes  the  sheets  stick  to  his 
feet,  another  that  this  is  the  "wandering  planet."  These  delu- 
sions are  not  supported  by  reason  or  logic,  and  seem  not  to  have 
been  at  all  assimilated  to  the  mentality  of  the  patient.  They  are 
false  ideas,  disconnected  from  the  general  content  of  thought  and 
existing  much  as  do  foreign  bodies  in  various  anatomical  locations. 

The  following  extract  from  the  history  of  an  old  case  of  precox 
of  the  hobo  type  shows  well  the  looseness  of  the  train  of  thought, 
the  weakness  of  judgment  shown  by  the  insufficiency  of  the  rea- 
sons given  for  certain  conclusions,  and  the  indifference  shown  by 
making  no  efifort  to  explain  or  understand  what  would  appear  to 
be  remarkable  occurrences. 

Two  years  ago  he  went  back  to  the  Old  Country  to  see  his  family.  On 
his  way  back  to  Arkansas  he  says  President  Roosevelt  was  on  the  same 
train  with  him,  and  that  the  President  made  him  give  up  his  seat.     He 

^  In  the  last  edition  of  his  Psychiatry  Kraepelin  describes  two  depressive 
types,  viz.,  simple  depression  or  stuporous  deterioration,  and  depressive 
deterioration  with  delusion  formation.  He  retains  dementia  simplex,  cata- 
tonia, and  the  paranoid  forms  (with  certain  variations)  and  describes  the 
rest  of  the  precox  group  under  these  two  depressive  heads,  a  form  of 
"silly"  deterioration,  corresponding  closely  to  the  hebephrenia  of  Kahl- 
baum  and  Hecker,  certain  circular,  agitated  and  periodic  types,  and  finally 
a  form  of  speech  confusion. 


1 68  OUTLINES   OF  PSYCHIATRY. 

knew  it  was  Roosevelt  because  he  looked  like  a  man  by  the  name  of  Rosen- 
thal who  owned  a  hardware  store  in  Batesville,  Ark.  Patient  states  that 
while  alone  on  the  farm  he  read  the  Bible  a  great  deal,  as  well  as  books 
about  spirits ;  that  through  their  perusal  he  learned  he  had  become  bald- 
headed  and  had  rheumatism,  and  had  strained  his  back.  As  the  result  of 
the  will  of  Martin  Luther,  acting  through  some  mortal,  he  said  his  neigh- 
bors would  keep  his  cattle,  hogs  and  horses  from  coming  home  at  night ; 
that  the  stock  became  poor  and  everything  seemed  to  go  against  him.  At 
night  he  was  troubled  by  someone  who  punched  him  and  kept  him  awake. 
He  was  not  relieved  of  this  annoyance  until  he  put  a  piece  of  money  in  his 
shotgun.  He  recalls  seeing  two  stars  travelling  toward  each  other,  one 
from  the  south  pole,  the  other  from  the  north,  and  the  next  night  there 
were  seven  stars  arranged  about  the  moon.  He  did  not  know  the  signifi- 
cance of  these  phenomena.  About  the  middle  of  February  he  said  he  was 
playing  cards  with  a  friend  whom  he  asked  who  was  elected  President. 
The  friend  told  him  that  there  was  no  one  on  the  ticket.  Patient  came  to 
Washington  a  little  later  (March  i,  1909)  to  see  if  he  could  not  secure 
the  position  of  President,  and  also  to  ask  Roosevelt  what  was  meant  by 
making  him  give  up  his  seat  on  the  train  two  years  ago.  On  arriving  in 
Washington  patient  went  to  the  Capitol  and  inquired  about  getting  a  room, 
told  of  his  troubles  with  Roosevelt,  and  was  immediately  turned  over  to 
the  Police  Department. 

The  emotional  deterioration  is  prominently  in  evidence.  One 
patient  says  enemies  are  following  him,  and  that  he  has  been 
killed  a  number  of  times ;  another  that  the  other  patients  are  try- 
ing to  injure  him.  These  facts  are  told  with  no  show  of  emotion, 
in  a  decidedly  matter  of  fact  way. 

In  the  cases  that  are  not  profoundly  deteriorated  a  certain /oo.y^- 
ness  of  the  train  of  thought  is  noticeable.  One  patient  tells  me 
that  he  has  been  ordained  by  the  Lord  to  preach — that  we  are 
all  put  here  to  do  the  best  we  can — that  the  bread  in  the  hospital 
is  impure — that  he  enlisted  on  a  certain  date  in  a  certain  regiment 
— that  when  he  first  came  to  the  hospital  he  was  not  well  in  mind 
or  body,  etc.  This  superficiality  resembles  flight  of  ideas,  but 
there  is  none  of  the  pressure  of  activity  of  manic-depressive  psy- 
chosis, and  while  the  changes  in  direction  of  the  train  of  thought 
are  abrupt,  they  are  not  sudden,  and  the  degree  of  incoherence 
is  much  greater.  The  speech  is  deliberate  aqd  there  does  not 
appear  to  be  any  distractibility.  The  condition  is  due  rather  to 
loose  connection  between  the  elements  in  the  train  of  thought 
and  to  poverty  of  ideas.  In  some  of  the  more  excited  phases  of 
dementia  precox  we  do  find  a  close  resemblance  to  flight  of  ideas 


DEMENTIA   PRECOX.  I69 

and  these  patients  are  often  difficult  to  differentiate  from  manic- 
depressives. 

These  patients,  like  the  cases  of  heboidophrenia,  often  exhibit 
peculiar  habits  and  mannerisms — a  tendency  to  repeat  certain 
phrases,  suggestibility,  unusual  attitudes,  or  a  certain  muscular 
tension,  shown  by  angularity,  clumsiness,  and  restraint  in  their 
movements.  Among  these  symptoms  is  often  noted  a  silly  laugh 
which  is  frequently  developed  while  the  patient  is  talking  to  him- 
self, but  which  may  occur  at  any  time  with  absolutely  no  apparent 
cause.  If  the  patient  is  asked  for  an  explanation  of  why  he 
laughed  he  will  reply  in  a  characteristic  manner,  "  I  don't  know," 
or  else  give  some  shallow,  wholly  inadequate,  or  manifestly  false 
reason^  These  various  symptoms,  with  the  exception  perhaps  of 
the  silly  laugh,  all  go  to  show  the  fundamental  alliance  between 
this  form  of  dementia  precox  and  the  catatonic  variety  next  to 
be  described. 

In  conduct  these  patients  usually  exhibit  a  condition  of  listless- 
ness,  apathy  and  disinterestedness  with  little  tendency  to  activity 
or  to  emotional  expression.  Alternating  conditions  of  depression 
and  excitement  may  and  often  do  occur  and  occasionally  the  dis- 
ease is  ushered  in  by  an  excitement  which  may  lead  to  a  diagnosis 
of  mania,  as  the  opposite  onset  we  have  seen  may  lead  to  a  diag- 
nosis of  melancholia. 

The  alternating  conditions  may  be  very  mild  as  in  the  case  of 
the  young  soldier  before  mentioned,  who  thought  he  was  ordained 
to  preach  and  that  the  bread  was  impure,  who  will  be  quiet  for 
several  months  and  then  exhibit  the  opposite  condition  for  a  few 
days  by  following  the  doctors  and  nurses  about  the  ward  telling 
them  his  troubles.  On  the  contrary,  the  alternations  may  be  be- 
tween conditions  much  more  extreme  as  in  the  case  of  a  patient 
who  alternates  between  a  state  of  stupor  and  a  state  of  excite- 
ment, in  which  he  eats  paper,  strings,  sticks,  and  bedecks  himself 
with  all  sorts  of  trash  he  collects  for  that  purpose,  at  times  be- 
coming violently  angry  and  cursing  every  one.  This  more 
marked  alternation  is,  however,  somewhat  more  characteristic  of 
catatonia. 

In  these  excited  conditions  in  cases  in  which  dementia  is  well 
marked  the  form  of  thought  becomes  greatly  deranged,  and  there 
is  a  high  grade  of  incoherence  amounting  to  confusion  of  thought 


I/O  OUTLINES  OF  PSYCHIATRY. 

and  the  speech  shows  absolute  incoherence,  a  mere  jumble  of 
words  expressing  only  fragments  of  ideas.  A  veritable  word- 
salad  {Salade  de  mots  of  Forel),  often  with  neologisms. 

The  following  is  a  stenogram  from  such  a  case.  Note  the 
neologism  prestigitis: 

"  How  old  are  you?  "  "  Why,  I  am  centuries  old,  sir."  "  How  long  have 
you  been  here?  "  "  I  have  been  now  on  this  property  on  and  off  for  a  long 
time.  I  cannot  say  the  exact  time,  because  we  are  absorbed  by  the  air  at 
night,  and  they  bring  back  jpeople.  They  kill  up  everything ;  they  can  make 
you  lie;  they  can  talk  through  your  throat."  "Who  is  this?"  "Why,  the 
air?"  "What  is  the  name  of  this  place?"  "This  place  is  called  a  star." 
"Who  is  the  doctor  in  charge  of  your  ward  "  "A  body  just  like  yours, 
sir.  They  can  make  you  black  and  white.  I  say  good  morning,  but  he  just 
comes  through  there.  At  first  it  was  a  colony.  They  said  it  was  heaven. 
These  buildings  were  not  solid  at  the  time,  and  I  am  positive  this  is  the 
same  place.  They  have  others  just  like  it.  People  die  and  all  the  microbes 
talk  over  there,  and  prestigitis  you  know  is  sending  you  from  here  to 
another  world."  "Do  you  know  what  year  this  is?"  "Why,  centuries 
ago."  "Do  you  know  who  discovered  America?"  "Yes,  sir;  Columbus." 
"What  year?"  "  1492;  they  have  had  several  discoveries  since  then,  sir." 
"  When  was  the  Civil  War  ?  "  "  That  was  in  1864-1860-1864."  "  Who  was 
the  President  of  the  United  States  at  that  time?"  "Well,  let  me  see; 
they  make  you  over  again,  sir."  "When  did  you  enter  the  army?"  "I 
entered  the  army,  why  it  was  centuries  and  centuries  ago ;  not  I  but  a  body 
just  like  my  remembrance  around  1903."  "Were  you  ever  in  Cuba?" 
"Yes,  sir;  I  was  there  three  times.  That  was  centuries  ago;  not  I  but  my 
remembrance,  because  I  have  been  killed ;  yes,  I  have  been  killed,  I  am 
positive  of  that.  Over  there  originally — originally  means  first — they  re- 
make us.  There  are  other  stars  like  this.  I  was  sent  by  the  government  to 
the  United  States  to  Washington  to  some  star,  and  they  had  a  pretty  nice 
country  there.  Now  you  have  a  body  like  a  young  man  who  says  he  is  of 
the  prestigitis"  "Who  was  this  prestigitis?"  "Why,  you  are  yourself. 
You  can  be  a  prestigitis.  They  make  you  say  bad  things;  they  can  read 
you;  they  bring  back  negroes  from  the  dead." 

III.  Catatonia. 

Like  the  other  forms  of  dementia  precox  which  have  been 
described  this  form  is  usually  of  subacute  or  chronic  onset,  being 
preceded  by  symptoms  of  insomnia,  confusion,  headache,  loss  of 
appetite,  emaciation  and  the  like.  The  disease,  on  the  contrary, 
is  sometimes  of  sudden  onset,  in  which  case  it  is  apt  to  be  the 
result  of  a  suddenly  depleting  cause  like  the  loss  of  blood  or  some 


DEMENTIA   PRECOX.  I/I 

severe  emotional  shock  or  fright.  In  these  cases  the  patient  may 
become  at  once  profoundly  stuporous. 

The  initial  stages  are  usually  marked  by  a  mild  grade  of  depres- 
sion, as  in  other  forms,  giving  the  appearance  of  melancholia. 
Hysterical  attacks  and  in  some  cases  epileptiform  convulsions 
may  occur  during  this  period. 

Following  the  more  or  less  vague  symptoms  of  the  prodromal 
period  occur  the  typical  symptoms  of  the  disease  which  group 
themselves  into  two  stages  which  irregularly  alternate,  viz.,  cata- 
tonic stupor  and  catatonic  excitement. 

In  catatonic  stupor  the  principal  symptoms  are  stupor,  nega- 
tivism and  muscular  tension.  In  the  extreme  cases  the  patient 
lies  perfectly  still,  without  making  any  movement  whatever  and 
not  reacting  at  all  to  stimuli.  Questions  are  paid  no  attention  to 
whatever,  absolute  m^utism  being  the  rule,  while  sensory  stimuli 
of  very  considerable  strength  may  be  applied  without  eliciting  any 
response. 

The  mutism  is  one  of  the  manifestations  of  negativism  which 
usually  shows  itself  in  various  ways.  The  patient  not  only  re- 
fuses to  eat,  but  pays  no  attention  to  the  calls  of  nature,  per- 
mitting the  bladder  and  rectum  to  become  overloaded  with  urine 
and  faecal  matter,  often  to  a  serious  extent;  he  likewise  allows 
the  saliva  to  collect  in  his  mouth  for  hours  at  a  time  until  putre- 
factive changes  have  occurred,  and  then  only  perhaps  as  a  result 
of  insistence  by  the  nurse  belches  forth  this  mass  of  stinking  fluid. 
Any  effort  to  get  the  patient  to  do  anything  is  immediately  met  by 
a  response  diametrically  opposed  to  the  desired  act.  If  asked  to 
show  the  tongue  the  lips  are  tightly  closed;  if  asked  to  open  the 
eyes  they  are  closed,  if  already  open,  or,  if  closed,  the  lids  are 
pressed  more  tightly  together  by  the  orbicularis. 

Attempts  to  move  the  body  are  met  by  marked  resistance  and 
elicit  the  condition  of  m.uscular  tension.  The  limbs  are  quite  rigid, 
often  stretched  out  stiffly,  the  fist  perhaps  tightly  clenched,  or, 
again,  the  extremities  of  the  body  as  a  whole,  perhaps,  may  rigidly 
occupy  some  peculiar  position.  This  muscular  tension  is  often 
shown  in  grimaces,  certain  facial  muscles  continuing  in  contrac- 
tion and  giving  strange  and  peculiar  expressions  to  the  coun- 
tenance. Thus  we  find  that  the  patient  maintains  a  constant  ex- 
pression of  scowling,  or  keeps  the  eyes  tightly  closed,  the  cheeks 


1/2  OUTLINES   OF   PSYCHIATRY, 

puffed  out,  or  perhaps  the  lips  closed  and  protruded,  producing 
the  condition  called  by  the  Germans  "  Snautzkrampf." 

Quite  the  reverse  of  this  picture  of  negativism  and  muscular 
tension  is  seen  in  other  cases.  In  the  place  of  muscular  tension 
we  find  a  condition  of  remarkable  flexibility,  so  that  the  limbs 
may  be  molded  into  any  position  desired,  and  though  quite  un- 
usual, they  are  maintained  there  indefinitely — catalepsy — if  raised, 
until  gravity  and  fatigue  cause  them  to  fall.  This  condition  is 
known  as  flexibilitas  cerea  (waxy  flexibility). 

With  this  condition  is  also  found  the  opposite  state  of  nega- 
tivism, namely,  suggestibility  or  command  automutism.  Patients 
in  this  condition  do  mechanically  just  what  they  are  told.  This 
condition  of  heightened  suggestibility  may  be  so  marked  as  to 
produce  echolalia — a  repetition  of  words  and  phrases  spoken  to 
them,  and  echopraxia — a  repetition  of  movements  in  their  pres- 
ence. These  symptoms  are  often  noted  during  the  examination, 
when  it  is  observed  that  the  questions  of  the  examiner  are  re- 
peated by  the  patient — in  whole  or  in  part — and  that  also  many  of 
his  movements  may  also  be  repeated,  such,  for  example,  as  look- 
ing at  his  watch,  putting  the  hand  to  the  face,  and  the  like. 

The  condition  of  catatonic  stupor  alternates  with  catatonic  ex- 
citement. Here  we  find  symptoms  manifesting  themselves  by 
activity  as  opposed  to  the  general  condition  of  passivity  or  quies- 
cence in  the  stuporous  patients. 

The  marked  cases  of  catatonic  excitement  are  constantly  talk- 
ing, shouting,  throwing  themselves  about  on  the  bed,  and  gener- 
ally manifesting  a  condition  of  increased  psychomotor  activity, 
reminding  one  very  much  at  first  of  the  manic  stage  of  manic- 
depressive  psychosis.  The  actions  are,  however,  much  more  ab- 
surd, not  directed  consistently  to  any  end,  quite  incoherent  and 
often  interrupted  by  attitudinizing,  hysteriform  attacks  and  stereo- 
typed movements — the  patients  repeating  over  and  over  again  cer- 
tain motions,  such  as  swaying  the  body  backwards  and  forwards, 
nodding  the  head,  swinging  the  arms  or  certain  other  motions 
characteristic  of  the  patient  and  which  have  no  apparent  signifi- 
cance. These  motions  are  often  accompanied  by  some  sound, 
such  as  a  grunt  or  blowing  sound,  or  by  the  continuous  repetition 
of  some  phrase. 


DEMENTIA   PRECOX,  I  73 

Verbigeration,  often  associated  with  senseless  rhyming,  is  quite 
common.    The  following  is  an  example : 

"  What  is  your  name  ?  "  "  How  old  are  you  ?  "  "  About  thirty."  "  How 
long  have  you  been  here?  "  "  A  couple  of  years."  "  What  do  you  do  most 
of  the  time?"  "Fold  shirts  in  the  laundry  and  mend  the  clothes."  "Do 
you  talk  to  yourself?  "  "  I  do  not  talk  to  myself;  talk  to  other  people,  also 
talk  to  all  the  people  I  run  across."  "What  do  you  talk  about?  "  "Talk 
about  the  weather,  etc."  "  What  is  that  you  say  to  yourself?  "  "  Locks  and 
keys,  keys  and  locks,  locks,  keys,  keys,  locks,  locks,  locks,  keys;  just  a  sort 
of  doggerel  [perseveration].  You  know  some  of  the  attendants  might  get 
hold  of  me  and  punch  me.  Locks,  keys,  keys,  locks,  locks,  keys,  keys, 
locks.  You  know  if  they  was  to  run  across  me  making  too  much  noise  they 
might  hurt  me."  "  What  do  you  say  locks  and  keys  for?  "  "  Just  to  enjoy 
myself.  You  know  there  are  times  when  there  is  nothing  doing,  and  I 
have  to  do  it  to  pass  away  the  time,  and  you  might  just  as  well  say  some- 
thing as  nothing."  "  What  did  you  say  the  other  night  to  the  students  ?  " 
"Told  them  about  locks  and  keys."  "What  else?"  "Myriads  of  us  keep 
growing  in  numbers,  also  in  largnesses;  locks  and  keys,  keys,  locks,  locks, 
keys,  keys,  locks,  locks,  keys,  keys,  locks.  Myriads  of  us  quick- foot  full 
through,  ev-er  no  mat-ter.  Locks,  keys,  keys,  locks,  locks,  keys,  keys. 
Myriads  of  us  ev-er  full  us  as  keep  lives  giant's  growths,  ev-er  lives  giant's 
keeper,  ev-er  no  mat-ter.  Locks,  keys,  keys,  locks,  locks,  keys,  keys,  locks. 
Lives  giant's  wealth,  health  and  pleasures,  ev-er  no  mat-ter.  Lives  sweet 
foreigners,  ev-er  no  matter."  "Can't  you  recite  some  more  poetry?"  "I 
cannot  give  any  more;  locks,  keys,  keys,  locks,  locks,  keys,  locks.  Me 
don't  know  any  more;  locks,  keys,  keys,  locks,  locks,  keys.  I  will  get  in 
trouble.  I  have  been  raking  away  at  it  outside  and  in  and  inside  out  again. 
I  have  tried  to  write  poetry,  but  could  not  write  any  more  than  six  fools." 

The  noisy  incoherent  talk  of  these  cases  might  readily  be 
thought  to  indicate  flight  of  ideas  but  the  incoherence  is  much 
greater  than  that  found  with  an  equal  grade  of  agitation  in  manic- 
depressive  psychosis,  and  there  is  no  trace  of  a  guiding  thought 
in  the  form  of  a  goal  idea.  The  patient,  too,  does  not  show  dis- 
tracftibility  to  the  same  extent,  being,  on  the  contrary,  quite  inac- 
cessible, paying  no  attention  whatever  to  what  is  being  said  or 
done  by  others,  not  even  making  any  pretense  to  answer  ques- 
tions, though  often  repeated. 

This  illustration  shows  well  the  perseveration  in  the  field  of 
speech.  A  single  motor  impulse  gets  the  field  and  holds  it;  the 
same  word  or  phrase  is  repeated  over  and  over  again.  A  quite 
similar  disturbance  is  seen  in  the  various  types  of  stereotypy.  In 
the  speech  field  this  manifests  itself  by  a  tendency  to  the  use  of 


174  OUTLINES   OF  PSYCHIATRY. 

set,  unchangeable  sentences.  One  of  my  patients  whom  I  met 
every  evening  on  leaving  my  office  used  invariably  to  say :  "  Doc- 
tor, I  wish  you  would  go  to  the  city  with  me  this  evening,  have 
the  electricity  shut  off,  and  those  parties  arrested."  This  sentence 
for  months  was  never  varied  by  a  word  or  intonation  and  was 
elicited  every  time  I  came  within  speaking  distance.  Later  the 
last  phrase  was  left  off  and  then  the  abbreviated  form  was  con- 
tinued as  the  other  had  been.  There  seems  to  be  a  sort  of  coagu- 
lation of  the  motor  reactions ;  they  are  not  fluid.  The  same  thing 
occurs  in  other  motor  fields. 

Quite  characteristic  of  this  condition,  too,  are  the  impulsive 
acts  of  these  patients.  They  will  suddenly  and  with  absolutely 
no  warning  whatever  commit  some  act  of  violence,  such  as  as- 
saulting another  patient  or  breaking  out  a  window,  and  quite  as 
suddenly  lapse  into  their  previous  state.  It  is  quite  impossible  to 
get  any  adequate  information  as  to  the  cause  for  these  acts.  The 
patient  is  inaccessible  to  a  degree  and  either  gives  some  senseless 
reply  to  the  questions  asked,  a  puerile  reason,  perhaps,  or  retires 
behind  an  "  I  don't  know "  or  complete  silence.  These  attacks 
come  out  of  the  clear  sky,  cannot  be  foreseen,  and  make  these 
patients  at  times  very  dangerous. 

In  the  milder  cases  of  catatonic  excitement,  in  which  the  motor 
excitement  is  not  so  pronounced,  the  patients  are  quite  commonly 
characterized  by  the  development  of  certain  habits  of  action  in 
some  definite  particular.  These  peculiarities  are  known  as  ma7i- 
nerisms.  One  patient  must  slide  the  right  foot  backward  and 
forward  before  beginning  to  walk,  another  holds  the  fork  in  a 
peculiar  way,  another  walks  close  to  the  wall,  not  coming  out  into 
the  center  of  the  ward,  another  carefully  avoids  stepping  on 
cracks  in  the  sidewalk,  and  so  on  indefinitely. 

The  following  extract  from  a  case  record  shows  the  develop- 
ment of  many  characteristic  catatonic  symptoms: 

Male,  set.  19.  Sometime  in  the  earlj'  part  of  September,  1910,  after  he 
had  been  on  an  alcoholic  spree,  he  returned  to  the  ship  and  thought  he 
heard  his  shipmates  making  remarks  about  him  and  saying  they  were  going 
to  throw  him  overboard.  He  left  the  ship  and  went  to  the  police  station 
at  Newport  and  asked  the  police  to  lock  him  up ;  the  next  morning  the 
master  at-arms  came  after  him  and  he  was  locked  in  the  brig  of  the  ship. 
He  still  had  auditory  hallucinations  and  thought  he  could  hear  his  mother 
and  little  brother  talking  to  him ;  was  kept  several  days  in  the  Naval  Hos- 


DEMENTIA  PRECOX.  175 

pital  at  Newport  under  observation.  He  slept  little,  and  felt  very  nervous. 
Was  admitted  to  this  hospital  September  30,  1910.  Upon  arrival  here,  he 
wanted  to  see  a  priest — said  he  was  going  to  die,  that  he  heard  people 
saying  they  were  going  to  shoot  him,  said  he  felt  awful  scared,  and  every- 
body seemed  to  think  he  was  a  spy  here. 

In  October,  1910,  visual  and  auditory  hallucinations  were  the  most  promi- 
nent feature  of  his  case.  Voices  told  him  to  get  out  of  bed  and  remain 
out.  For  a  time  he  did  not  eat,  saying  something  prevented  his  swallow- 
ing; again  he  could  not  breathe;  something  closed  his  nose;  his  bowels 
were  obstructed  and  urine  was  retained;  saliva  was  allowed  to  accumulate 
in  his  mouth.  While  in  bed,  he  assumed  a  constrained  position;  his  head 
was  held  from  the  pillow  without  effort;  his  facial  expression  was  one  of 
dazed  confusion.  He  was  disoriented  for  time,  place  and  person,  said  he 
was  not  insane,  but  knew  that  every  one  around  him  thought  him  so.  He 
had  a  marked  condition  of  flexibilitias  cerea.  When  in  bed,  his  head  was 
frequently  raised  in  turtle-fashion  without  the  support  of  a  pillow.  About 
February  i,  191 1,  patient  began  to  improve  progressively.  At  that  time  he 
was  up  and  dressed  and  about  the  ward,  talked  more  freely  concerning  his 
past  experiences,  associated  quite  freely  with  the  other  patients,  asked  for 
the  privilege  of  doing  some  work,  and  rendered  quite  efficient  service  in 
the  ward  work.    His  insight  at  that  time  was  incomplete  and  imperfect. 

Physical  Symptoms. — The  physical  symptoms  of  catatonia  are 
much  more  prominent  than  in  any  other  form  of  dementia  precox. 

SHght  differences  in  the  size  of  the  pupils  are  common.  Pupil- 
lary unrest  (hippus)  is  sometimes  observed;  quite  frequenly  a 
marked  degree  of  mydriasis  is  present,  while  the  phenomenon  of 
Pilz  is  sometimes  found.  The  tendon  reflexes  are  usually  exag- 
gerated. The  cutaneous  sensibility  is  lowered.  Vasomotor  dis- 
turbances are  often  seen,  giving  rise  to  cold,  cyanosed  extremities 
in  the  stuporous  cases.  With  this  condition  may  be  associated 
dermographia.  The  secretions  are  disturbed,  the  sweat  and 
saliva  may  be  increased,  the  urine  scanty  or  increased,  and  con- 
stipation may  previal.  Loss  of  weight  is  common  in  the  active 
stages  of  this  disease. 

VI.   Paranoid  Forms. 

There  has  been  a  great  deal  of  discussion  as  to  just  what  cases 
should  be  properly  included  under  this  heading.  It  is  inevitable, 
as  long  as  the  paranoia  concept  itself  is  so  poorly  defined,  that 
the  paranoid  forms  of  mental  disease  should  also  be  difficult  to 
classify. 


1/6  OUTLINES    OF   PSYCHIATRY. 

The  fundamental  fact  is  that,  in  dementia  precox,  cases  pre- 
senting paranoid  syndromes — delusions  of  persecution  or  gran- 
deur, somewhat  systematized,  with  perhaps  hallucinations  of  hear- 
ing, are  found. 

The  difficulty  is  that  some  writers  object  to  the  inclusion  of 
certain  forms  in  the  category  of  dementia  precox,  others  question 
the  propriety  of  the  inclusion  of  the  same  forms  under  the  head 
of  paranoia.  Many  authors,  for  example,  definitely  include  Mag- 
nan's  dclire  chronique  as  a  form  of  paranoid  dementia  precox. 

If  dementia  precox  is  to  be  considered  as  fundamentally  a 
deterioration  psychosis,  then  symptoms  of  deterioration  associated 
with  the  paranoid  syndrome  are  to  be  expected.  In  the  last  edi- 
tion of  his  Psychiatry  Kraepelin,  however,  has  included  only 
two  paranoid  types,  a  mild  and  a  grave,  and  has  removed  the 
group  of  dementia  paranoides  as  well  as  all  other  cases  which 
show  a  disturbance  preponderantly  in  the  intellectual  field  and  fail 
to  show  the  affection  of  the  will  and  affect  with  the  serious  di- 
lapidation of  the  personality  characteristic  of  precox,  to  a  new 
group  which  he  designates  paraphrenia.  This  group  he  splits  up 
into  four  divisions  as  follows: 

1.  P.  systematica. — This  practically  includes  Magnan's  delire 
chronique  except  that  well  defined  precox  deteriorations  are  not 
excluded. 

2.  P.  expansiva. — Occurs  only  in  women  and  is  marked  espe- 
cially by  the  development  of  ideas  of  grandeur  with  mild  exal- 
tation. 

3.  P.  confabulans. — Here  the  delusional  system,  presenting 
both  persecutory  and  grandiose  components,  has  its  foundation  in 
memory  falsifications. 

4.  P.  phantastica. — In  this  group  the  patients  show  a  moderate 
degree  of  exaltation  and  a  tendency  to  the  recounting  of  remark- 
able adventures. 

The  difficulty  of  differentiating  the  conditions  in  their  early 
stages  is  often  very  great  if  not  quite  impossible.  Since  paranoia 
is  no  longer  considered  to  be  a  purely  intellectual  disorder  its 
early  stages  are  known  to  be  marked  by  emotional  depression. 
This  same  condition  of  emotional  depression  in  the  prodromal 
period  of  dementia  precox  is  found.  If,  then,  a  boy  eighteen  or 
twenty  years  old  has  a  fairly  well  organized  delusional  system 


DEMENTIA  PRECOX.  1 77 

and  is  somewhat  depressed,  showing  httle  evidence  of  intellectual 
impairment,  perhaps  only  a  desire  to  seclude  himself,  with  an 
apparent  inability  to  apply  his  mind  consistently  to  any  end,  it 
is  difficult  to  know  whether  an  incipient  paranoia  of  a  dementia 
precox  is  in  the  making. 

When,  however,  a  patient  gives  a  history  of  a  comparatively 
acute  onset,  with  the  usual  symptoms  of  insomnia,  depression, 
loss  of  appetite  and  some  emaciation;  and  an  examination  reveals 
a  loosely  organized  delusional  system,  the  delusions  of  which  are 
numerous,  fantasic  and  often  changeable,  associated  with  numer- 
ous fleeting  hallucinations,  such  a  patient  is  to  be  regarded  as  one 
of  dementia  precox  (Kraepelin).  This  diagnosis  is  especially 
warranted  if  in  addition  to  the  above  symptoms  evidences  of 
muscular  tension,  stereotypy,  verbigeration,  automatism,  manner- 
isms, suggestibility  or  negativism  are  found,  these  symptoms,  as 
has  been  pointed  out,  being  found  in  all  the  varieties  of  dementia 
precox  in  varying  degrees  and  combinations,  and  seeming  to  show, 
as  does  dementia,  the  underlying  unity  of  the  several  different 
forms. 

In  some  of  these  paranoid  forms  the  hallucinations  play  a  very 
prominent  part;  in  others  they  have  less  significance.  The  delu- 
sions are  not  infrequently  of  a  grandiose  nature  and  such  patients 
often  decorate  themselves  very  lavishly  with  all  sorts  of  orna- 
ments and  insignia,  usually  made  by  themselves.  They  are  the 
patients  that  are  known  as  fantastic  paranoiacs. 

The  following  extract  from  a  case  record  shows  a  character- 
istic type  of  delusional  formation  in  a  paranoid  type : 

Male,  aet.  ^2  years.  On  admission  to  this  hospital  the  patient  was  well 
oriented  in  all  spheres,  showed  no  clouding  of  consciousness,  was  neat  in 
appearance  and  tidy  in  habits,  took  a  normal  interest  in  his  surroundings, 
assisted  with  the  ward  work,  and  adapted  himself  readily  to  his  new  en- 
vironment. He  showed  no  disturbance  emotionally  as  a  rule,  but  when 
the  subject  of  his  sojourn  here  was  broached,  he  worked  himself  up  into 
a  slight  passion.  He  gave  evidence  of  being  slightly  suspicious,and  on  one 
or  two  occasions  exhibited  delusions  of  reference.  He  elaborated  a  fairly 
well  organized  system  of  persecutory  delusions  in  which  many  people  were 
involved,  among  these,  some  high  officials  in  the  Army  and  Navy,  and  this 
delusional  system  took  its  inception  in  the  latter  part  of  1908,  while  the 
patient  was  a  member  of  the  Seamen's  Gunners'  Club  at  Washington,  D.  C. 
He  claims  that  the  first  trouble  started  through  the  instigation  of  certain 
false  accusations  by  fellow  Masons,  that  the  men  at  the  class  tried  in  every 


178  OUTLINES    OF   PSYCHIATRY. 

way  to  make  life  miserable  for  him,  that  he  had  heard  them  call  him 
various  unmentionable  names,  with  a  view  of  blemishing  his  character. 
On  one  occasion  they  administered  to  him  an  overdose  of  iron,  quinine 
and  strychnine,  on  another,  they  tried  to  poison  his  food.  They  refused  to 
eat  with  him  at  the  same  table,  had  detectives  watch  him,  etc.  He  says 
back  of  all  this  stood  some  high  officials  of  the  Navy  and  Army,  that  he 
saw  one  of  these  give  the  sign  to  the  other  man  to  torture  the  patient,  that 
the  reason  these  officials  had  them  persecuting  him  was  the  fact  of  the 
patient's  invention  of  some  dirigible  aero  torpedoes  with  proper  detonators, 
and  these  officials  stole  the  patent  from  the  patient  and  then  sold  it  to  the 
combination  of  three  European  countries;  and  it  was  to  their  interest  to 
get  rid  of  the  patient  in  some  way  in  order  that  he  should  not  expose 
them,  as  he  had  knowledge  of  this  treasonable  transaction. 

V.   Mixed  Forms. 

As  previously  mentioned  the  several  forms  described  are  not 
always  clean-cut.  The  simple,  hebephrenic  and  paranoid  often 
present  symptoms  that  are  more  characteristically  developed  in 
the  catatonic.  These  mixed  forms  are  in  reality  very  common 
indeed  and  in  fact  almost  constitute  the  rule. 

Course  and  Progress. — The  simple  and  paranoid  forms  are  the 
slowest  of  evolution  and  almost  chronic  in  course,  the  paranoid 
forms  often  remaining  in  statu  quo  for  two  or  three  years.  The 
hebephrenic  and  catatonic  forms  are  more  acute  in  onset  and 
course,  leading  more  rapidly  to  dementia  in  the  majority  of  cases, 
although  the  catatonic  form  has  rather  the  better  prognosis. 

Remissions  occur  especially  in  the  catatonics.  According  to 
Kreapelin,  8  per  cent,  of  the  hebephrenics  (including  the  group 
of  simple  dementia)  and  13  per  cent,  of  catatonics  make  practical 
recoveries,  but  some  of  these  cases  relapse.  The  paranoid  cases 
do  not  get  well.  The  tendency  of  all  forms  is  to  a  gradually 
deepening  deterioration. 

Recently  Zablocka^**  in  a  study  of  515  cases  found  that  60  per 
cent,  proceeded  to  light,  18  per  cent,  to  medium,  and  22  per  cent, 
to  severe  dementia.  The  cases  which  develop  in  persons  with 
the  "  shut  in  "  type  of  character  show  the  worst  outcome. 

KoLPiN^^  in  a  study  of  100  cases  tabulates  his  results  as  follows : 

^0  Zablocka,  Marie-Emma :  Zur  Prognosestellung  bei  der  Dementia  prae- 
cox,  Allg.  Zeit.  f.  Psych.,  Bd.  LXV. 

11  Kolpin :  t)ber  Dementia  praecox,  insbesondere  die  paranoide  Form 
desselben.    Allgemeine  Zeitschr.  f.  Psychiatrie,  Mch.,  1908. 


DEMENTIA  PRECOX.  1/9 

Earliest  Latest 

Cases.  Beginniog.  Beginning^. 

31  Hebephrenia 14  38 

30  Catatonia 17  48 

39  Paranoid  16  51 

and  comes  to  the  additional  conclusions  regarding  the  a:bove 
forms  of  the  disease.  The  hebephrenic  form  results  in  simple 
dementia  in  a  few  cases.  There  are  only  rarely  remissions  and 
the  course  is  generally  continuous,  with  increasing  dementia. 
Only  the  severe  grades  and  the  dependents  get  into  the  asylum. 
The  onset  is  more  insidious  in  women  than  in  men.  In  the  cata- 
tonic form  the  onset  is  acute  or  subacute.  A  half  of  the  cases 
begin  with  depression,  a  quarter  begin  with  excitement.  There 
are  more  often  remissions  in  this  form  than  in  hebephrenia.  The 
beginning  of  the  paranoid  form  is  more  or  less  chronic.  In  four 
of  the  cases  studied  the  origin  was  acute  or  subacute.  The  results 
in  this  form  are: 

(a)  Systematization  of  delusions  with  many  hallucinations. 
These  hallucinations  may  be  wonderful,  etc.  (fantastic  paranoia). 
These  cases  are  not  numerous  and  do  not  present  much  defect. 

(b)  The  commonest  form,  the  building  of  a  poor  system  of 
delusions,  which  earher  or  later  comes  to  a  standstill.  There  is 
depression  and  irritability  and  not  much  defect. 

(c)  The  delusions  are  loosely  organized,  disappear  and  become 
confused  or  in  great  numbers  and  are  fantastic.  There  is  no 
increasing  dementia,  irritability  decreases  and  the  patient  becomes 
comfortable,  stupid,  confused,  then  productive  with  word  salad. 

The  question  whether  a  cure  in  the  sense  of  a  restitutio  ad 
integram  ever  takes  place  is  still  a  mooted  one,  some  observers 
claiming  that  every  case  of  remission  will  show  defect  if  exam- 
ined with  sufficient  care  Mlle.  Pascal^^  speaks  of  abortive  cases 
beginning  with  pseudo-neurasthenia.  These  abortive  cases  and 
the  cases  of  remission  in  the  early  stages  show  defects  only  of 
mild  degree  and  largely  in  the  higher  faculties.  Many  of  these 
cases  go  to  swell  the  ranks  of  the  criminals,  the  prostitutes,  and 
the  hoboes,  and  are  often  mistaken  for  cases  of  feeblemindedness. 
WiLMANNS^^  in  a  study  of  127  vagabonds  found  that  66  could 
be  classified  as  dementia  precox. 

12  Mile.  Pascal :  Les  remissions  dans  la  demence  precoce,  Revue  de  Psy- 
chiatric, 1907. 

13  Cited  by  Mlle.  Pascal. 


l8o  OUTLINES   OF   PSYCHIATRY. 

Diagnosis. — The  diagnosis  of  dementia  precox,  while  compara- 
tively easy  in  the  well  defined  and  advanced  cases,  becomes  a 
matter  of  great  difficulty  in  certain  instances. 

Certain  forms  of  manic-depressive  psychosis  present  charac- 
teristic difficulties,  particularly  the  mixed  forms.  Here  it  is  often 
necessary  to  find  a  history  of  repeated  attacks  without  deteriora- 
tion in  order  to  feel  sure  that  it  is  not  dementia  precox.  The 
depression,  which  so  frequently  occurs  as  an  early  symptom  in 
precox,  may  readily  be  mistaken  for  the  depression  of  the  manic- 
depressive  psychosis,  the  retardation  of  this  psychosis  being  very 
similar  in  its  outward  manifestations  to  the  negativism,  the  an- 
tagonism, the  inaccessibility  and  particularly  the  lack  of  interest 
of  the  precox  patient.  If  there  are  delusions,  however,  the  manic- 
depressive  is  more  apt  to  have  delusions  of  a  self -accusatory  type, 
while  the  precox  type  is  more  likely  to  have  delusions  of  a  gro- 
tesque character,  and  to  refer  the  origin  of  his  delusions  to  causes 
outside  of  himself.  The  pressure  of  activity  of  the  manic- 
depressive  has  outward  similarities  to  the  excitement  of  the  cata- 
tonic. In  the  former,  however,  the  activity,  although  rapidly 
changing  in  its  object,  characteristically  is  addressed  to  some  par- 
ticular purpose,  while  with  the  catatonic  the  activity  is  more 
diflfuse  and  has  less  direction.     It  is  incoherent. 

In  the  early  stages  the  mild  depression  of  the  precox  may  simu- 
late that  of  the  neurasthenic,  or  the  agitated  depression  may  simu- 
late that  of  the  anxiety  neurosis.  In  both  instances  the  precox  is 
more  apt  to  show  grotesque  delusions  and  conduct  disorders  of  a 
bizarre  nature,  such  as  tearing  up  his  clothes,  mutilating  himself, 
or,  on  the  Other  hand,  characteristic  negativistic  symptoms,  such 
as  retaining  the  saliva  or  the  urine,  withdrawing  from  all  eflforts 
to  do  for  him,  refusing  to  cooperate  in  changing  his  clothing,  the 
refusal  of  food  and  the  like. 

The  epileptiform  and  hysteriform  episodes  may  lead  to  a  diag- 
nosis of  epilepsy  or  hysetria.  It  must  not  be  forgotten,  however, 
that  it  is  possible  to  have  precox  complicated  with  epilepsy,  and 
that  many  of  the  symptoms  of  precox,  if  taken  in  their  cross  sec- 
tion without  a  study  of  the  life  history  of  the  individual,  arc  dis- 
tinctly hysterical  in  character. 

From  the  infection  and  exhaustion  psychoses  the  diflFerentiation 
is  characteristically  extremely  difficult  at  the  height  of  the  attack. 


DEMENTIA   PRECOX.  l8l 

and  it  is  necessary  in  such  patients  who  are  suffering  from  a  dis- 
tinct type  of  infection  such  as  typhoid,  and  who  present  distinctly 
precox  symptoms,  to  wait  until  the  subsidence  of  the  infection  to 
see  whether  the  case  clears  up,  as  it  will  if  it  is  merely  an  infection 
psychosis.  Great  care  should  be  exercised  in  offering  a  prognosis 
in  these  cases.  Many  of  the  so-called  cases  of  puerperal  insanity 
are  really  cases  of  precox  which  have  been  precipitated  by  the  cir- 
cumstances of  the  puerperal  period,  loss  of  blood,  prolonged  labor, 
infection  or  the  mental  stress  incident  to  an  illegitimate  pregnancy 
particularly. 

From  paresis  the  differentiation  can  usually  be  made  definitely 
by  the  Wassermann  reaction  of  the  blood  serum  and  the  cerebro- 
spinal fluid,  for  both  of  which  it  will  be  positive  in  paresis,  and  by 
an  examination  of  the  cell  content  of  the  cerebrospinal  fluid  which 
will  show  an  increased  cell  content  and  quite  characteristically  the 
presence  of  one  or  more  plasma  cells  in  the  field. 

From  the  toxic  psychoses,  particularly  from  alcoholic  deteriora- 
tion, the  differentiation  is  often  quite  difficult.  It  must  be  borne 
in  mind  in  this  connection  that  the  relatively  healthy  man  deterio- 
rates very  slowly  from  the  use  of  alcohol,  while  it  is  found  in  the 
records  of  precox  cases,  who  have  indulged  in  alcohol,  that  the 
deterioration  has  come  on  relatively  much  earlier.  In  addition  to 
this,  it  will  be  found  that  the  amount  of  deterioration  in  the  precox 
case  is  very  much  greater  than  could  reasonably  be  explained  by 
the  alcoholic  indulgences  of  the  patient.  When  these  discrepancies 
in  the  history  are  found  we  are  justified  in  suspecting  that  we  are 
dealing  with  a  fundamentally  more  serious  condition  than  mere 
alcoholism.  Graeter"  in  a  valuable  monograph  has  called  at- 
tention to  this  combination  of  alcohol  and  precox,  and  it  is  ex- 
tremely important  to  bear  in  mind  particularly  from  the  point  of 
view  of  prognosis. 

Oftentimes  the  question  of  diagnosis  will  raise  as  between  an 
acquired  defect  due  to  precox  and  some  form  of  inherent  defec- 
tiveness. It  must  be  remembered  in  this  connection  that  precox 
may  develop  upon  a  defective  basis,  and  that  in  such  case  the  his- 
tory will  characteristically  show  the  symptoms  of  this  defective- 

^*  Graeter :  Dementia  Praecox  mit  Alcoholismus  Chronicus.  Eine  klin- 
ische  Studie  iiber  Demenz  und  chronisch  paranoide  Psychosen  scheinbar 
alkoholischer  Natur.    Leipzig,  1909. 


1 82  OUTLINES  OF  PSYCHIATRY. 

ness,  such  as  poor  progress  in  school,  and  inability  to  learn  in  the 
various  occupations  in  which  the  patient  has  been  engaged.  The 
symptomatology  itself  may  also  indicate  this  original  defect,  as 
for  example  the  following  production  of  such  a  patient  shows 
quite  clearly  the  lack  of  knowledge  which  comes  from  lack  of 
education  at  least,  and  would  lead  to  the  suspicion  of  an  inherent 
defect. 

there  is  signety  to  vocle  word  i  have  the  sin  i  am  not  edicat  every  body 
wall  love  this  sin  it  will  be  easy  to  lorn  for  you  but  burden  for  me  i  am  A 
labor  willen  to  wark  i  can  do  beter  if  my  sine  is  excaped  it  wall  be  grate 
and  wondful  for  the  they  will  love  it  to  it  was  A  puzle  to  be  but  not  to 
them  Silas  Johnson  of  United  States  Amicar  dont  think  I  am  crazy  i  dont 
know  whethe  cristfer  clumers  was  or  not. 

Pathology. — There  is  very  little  that  is  distinctive  in  the  somatic 
pathology  of  dementia  precox.  In  the  same  way  that  the  clinical 
symptoms  are  widely  diffused  and  rather  indefinite  so  it  is  with 
the  pathological  findings.  A  certain  amount  of  degenerative 
change  is  often  found  in  the  cortical  cells,  while  some  observers 
have  found  that  these  cells  are  fewer  in  number  than  normal. 
The  neuroglia  is  quite  frequently  found  increased  in  amount. 
In  the  other  organs  the  changes  are  inconsiderable.  Beginning 
degenerative  changes  may  be  found  in  the  vessels  and  tuber- 
culosis is  not  an  infrequent  complication. 

More  recently,  however,  the  way  seems  to  be  opening  up  for 
something  more  definite  in  the  pathology  of  this  disorder.  Alz- 
heimer^^ had  been  working  on  the  degeneration  products  of  the 
nervous  tissues  and  thought  he  had  found  distinctive  changes  and 
enough  to  write  down  dementia  precox  as  an  organic  brain  dis- 
ease. SouTHARD^^  has  recently  described  certain  anomalies  as 
scleroses  which  he  has  found  in  precox  brains.  These  anomalies 
tend  to  group  themselves  in  certain  regions.  The  frontal  region 
is  often  involved  and  it  is  interesting  to  note  that  he  finds  a  cere- 
bellar group  of  cases  corresponding  to  those  presenting  catatonic 
symptoms.  His  group  roughly  correspond  to  the  groups  clin- 
ic Alzheimer:  Beitrage  zur  Kentniss  der  pathologischen  Neuroglia  und 
ihrer  Beziehungen  zu  den  Abbauvorgangen  im  Nervengewebe.  Histol.  u. 
Histopath.  Arbeiten,  1910. 

15  Southard,  E.  E. :  A  Study  of  the  Dementia  Praecox  Group  in  tHe 
Light  of  Certain  Cases  Showing  Anomalies  or  Scleroses  in  Particular 
Brain  Regions,  Am.  Jour,  of  Insanity,  July,  1910. 


DEMENTIA  PRECOX.  1 83 

ically  showing  most  prominently  intellectual  disorder  (paranoia), 
and  motor  disorder  (catatonic),  while  the  emotional  disorders  of 
precox,  most  prominently  seen  perhaps  in  the  hebephrenic  va- 
riety, have  been  supposed  to  be  due  to  lesions  in  certain  deep 
layers  of  the  cortex^"'  which  have  no  direct  motor  or  sensory  or 
perhaps  associational  relations. 

Nature  of  Dementia  Precox. — From  the  discussion  of  dementia 
precox  up  to  this  point  it  will  be  seen  that  it  has  certain  similarities 
to  the  organic  brain  diseases  like  paresis  on  the  one  hand,  and  to 
the  more  purely  functional  disorders  such  as  hysteria  on  the  other 
hand.  It  would  seem  to  stand  midway  between  the  so-called 
organic  and  psychogenic  psychoses. 

It  is  allied  to  paresis,  for  example,  on  the  anatomical  side  by 
its  pathology — the  degenerations — and  on  its  clinical  side  by  the 
underlying  progressive  deterioration  upon  which  as  a  basis  all 
manner  of  psychotic  symptoms  may  be  erected. 

It  is  allied  to  hysteria  by  its  frequent  apparent  psychogenic 
origin  and  by  the  similarity  of  the  psychic  mechanisms — the 
"  complex  "  formation  and  the  symptoms  to  which  it  gives  rise, 

Kraepelin,  taking  the  more  material  view,  puts  forward  the 
hypothesis  of  toxic  origin^ — from  perhaps  the  sexual  glands,  since 
it  appears  so  closely  associated  with  adolescence.  Jung^^  sees 
more  the  functional  origin  and  would  bring  in  the  toxemia  to 
acconut  for  the  non-recovery.  The  symptoms,  like  hysteria,  are 
fixed,  as  it  were,  like  the  photographic  plate  by  the  hypo  bath. 
He^^  thinks  the  affect  which  causes  the  complex  may  set  loose  a 
toxin.  The  affect-toned  complex  may  cause  the  mental  and  phys- 
ical symptoms  of  a  dementia  precox  in  the  same  way  that  an  in- 
fection may  follow  a  physical  trauma.  Still  further  light  may 
be  cast  upon  the  pathology  in  this  process  when  one  considers 
the  results  of  persistent  unconscious  affective  states  as  causing 
vegetative  nervous  system  disturbances  with  resultant  somatic 
changes.^" 

^^  Lugaro,  Ernesto :  Modern  Problems  in  Psychiatry,  1909. 

18  Jung,  C.  G. :  The  Psychology  of  Dementia  Praecox,  Nerv.  and  Ment. 
Dis.  Monog.  Series  No.  3. 

13  Bleuler,  E.,  und  Jung,  C.  G. :  Komplexe  und  Krankheitsursachen  bei 
Dementia  prascox,  Zentralb.  f.  Nervenheilk.  u.  Psychiatric,  Heft  6,  1908. 

-<>Jelliffe:  Vegetative  Nervous  System  and  Dementia  Prsecox,  New 
York  Medical  Journal,  1917. 


184  OUTLINES   OF   PSYCHIATRY. 

Reference  to  the  discussion  of  the  relation  of  mind  and  body 
in  Chapter  III,  where  mind  is  considered  as  reacting  by  mecli- 
anisms  which  are  both  psychical  and  physical — psychical  at  one 
extreme  and  physical  at  the  other  extreme — will  indicate  how  a 
disorder  which  is  ultimately  organic  in  nature  may  take  its  origin 
in  purely  mental  factors. 

It  is  of  great  importance,  however,  to  define  if  possible  the 
psychological  diflferences  between  hysteria  and  the  psychoneuroses, 
in  which  we  also  see  the  operation  of  complexes,  and  precox. 

The  superficial  and  obvious  diflference  seems  to  lie  in  the  char- 
acter of  the  psychic  splitting.  In  hysteria  and  the  psychoneuroses 
the  splitting  is  more  massive  while  in  precox  it  is  relatively  mole- 
cular. In  hysteria,  for  example,  the  symptoms  lead  back  to  actual 
situations,  while  in  precox  they  lead  back  only  to  fragments.  For 
example : 

A  young  woman — an  hysteric — believes  that  she  is  dead  and 
that  her  soul  has  separated  from  her  body.  The  explanation  is 
that  she  is  married  to  one  man  and  loves  another.  Spiritually 
she  belongs  to  her  lover,  physically  she  belongs  to  her  husband 
and  her  body  is  dead  because  only  in  this  way  can  she  justify  the 
continuation  of  physical  relations.  As  a  further  elaboration  of 
this  she  has  a  complete  anesthesia. 

A  precox,  while  having  some  difficulty  on  the  ward,  has  to  be 
restrained  and  cries  out  "  contract,"  "  contract."  It  appeared  on 
questioning  that  on  this  day  the  mortgage  on  his  father's  farm 
was  due.  His  father  had  often  had  to  ask  him  to  help  pay  it. 
Patient  then  spoke  of  a  "  four-sided  contract  burial."  It  had 
taken  four  persons  to  restrain  him.  Here  it  will  be  seen  that  the 
associations  are  only  with  fragments  of  situations.  There  was 
no  other  connection  with  his  trouble  except  that  it  occurred  on  the 
day  the  mortgage  was  due  and  so  a  quite  superficial  association 
was  formed. 

A  young  woman  precox  says  she  is  related  to  the  Empress  of 
Austria,  whose  name  is  Charlotte,  because  she  has  a  cousin  and 
an  aunt  by  the  name  of  Charlotte,  and  that  she  had  a  scarlet  (clang 
association)  dress  given  her  when  a  child. 

This  molecular  splitting  of  the  psyche  I  would  term  the  frag- 
mentation of  the  psyche  and  believe  it  to  be  an  abvious  psycho- 
logical characteristic  of  dementia  precox  at  the  descriptive  level. 


DEMENTIA   PRECOX.  18$ 

The  fact  is  that  in  precox  we  are  deahng  with  much  more  ma- 
lignant defects  of  biological  adjustment.  The  defect  strikes  much 
deeper  and  there  is  marked  inability  on  the  part  of  the  patient  to 
form  compensatory  adjustments  or  sublimations.  Probably  both 
the  depth  to  which  the  regressive  tendencies  reach  and  the  strength 
of  their  fixation  are  factors  in  determining  the  grade  of  ma- 
lignancy. 

The  content  of  the  symptoms  is  determined  by  the  nature  of 
the  complexes,  their  malignancy  by  the  recuperative  powers  of 
the  patient.  For  example :  the  hebephrenic  type  indicates  a  failure 
to  develop  any  adequate  defenses.  The  patient  frankly  expresses 
delusions  and  hallucinations  of  the  greatest  apparent  absurdity. 
If  the  process  comes  to  a  stand  still  there  is  an  adjustment  at  a 
relatively  low  level  as  for  instance  the  case  of  a  young  woman 
who  made  a  failure  of  her  love  life,  marriage  and  motherhood 
and  after  passing  through  a  few  weeks  of  confusion  and  stupor 
with  hallucinations  and  delusions  settled  into  a  fixed  stage  of  re- 
gression to  the  mental  state  of  a  little  girl  of  about  twelve  years 
of  age.  She  acts  like  a  child,  has  thrown  off  all  the  cares  of  adult- 
hood and  all  responsibility  for  her  family  and  the  natural  obliga- 
tions of  parenthood. 

The  catatonic  endeavors  to  shut  out  from  consciousness  his  con- 
flict by  a  supreme  effort  at  repression.  If  he  gets  well  it  is  often 
at  the  expense  of  a  large  portion  of  his  personality  which  he  can- 
not assimilate.^^ 

The  paranoid,  while  not  so  apt  to  recover,  is  able  to  build  a 
more  or  less  elaborate  world  of  phantasy  in  which  he  gets  along 
fairly  well.  Many  philosophies  and  new  religions  are  given  birth 
in  this  effort. 

The  relation  of  the  delusion  to  the  complex  is  often  obvious  if 
one  is  familiar  with  the  more  important  of  the  infantile  material. 
A  man  believes  himself  pregnant,  that  a  child  is  in  his  stomach. 
This  is  obviously  a  regression  to  the  period  when  as  an  infant  he 
had  not  understood  that  gestation  was  a  particular  function  of  the 

21 A  study  of  the  muscular  tensions,  vascular  reactions,  glandular  ac- 
tivities of  this  condition,  in  which  such  disturbances  are  so  marked,  along 
the  lines  of  their  meaning  as  being  part  and  parcel  of  certain  instinctive 
tendencies,  would  do  much  to  elucidate  the  meaning  of  the  symptoms  and 
might  also  equally  illuminate  the  instincts  from  the  physiological  side. 

13 


1 86  OUTLINES   OF   PSYCHIATRY. 

female.  Another  patient  enucleated  his  eye  (castration  symbol)  ; 
a  colored  man  of  about  forty  years  of  age  invented  a  perpetual 
motion  machine  (compensation  for  impotence)  ;  a  man  tries  to 
invent  the  greatest  cannon  on  earth  (compensation  for  small  penis 
complex)  ;  a  homosexual  man  of  the  "  sissy "  type  made  wild 
claims  of  physical  prowess,  fighting  ability,  and  incessantly  swore 
and  used  vulgar  language  to  demonstrate  his  toughness  (over- 
compensation of  homosexuality)  ;  a  woman  complains  that  her 
sister's  husband  follows  her  through  underground  passageways 
and  shoots  electricity  into  her  genitalia  and  anus  (anal  erotism)  ; 
an  oral  erotic  woman  starves  herself  in  order  to  be  tube  fed;  oral 
erotic  patients  often  cut  their  throats  while  under  the  erotic  pres- 
sure; patients  frequently  say  that  God  talks  with  them  or  go  to 
Washington  to  see  the  President  (father  complex)  ;  in  severe 
grades  of  introversion  they  sit  in  a  dark  corner,  head  on  breast, 
arms  folded  and  legs  and  thighs  flexed  (intra-uterine  position)  ; 
a  young  woman  says  her  real  parents  are  the  King  and  Queen  of 
Norway  (CEdipus  phantasy)  ;  etc.  Of  course  much  of  the  de- 
lusional material  is  not  so  obviously  related  to  infantile  material 
and  must  be  worked  out  at  length  with  the  individual  to  determine 
its  meaning. 

It  must  not  be  forgotten  that  a  precox  may  have,  however, 
complex  reactions  exactly  like  that  of  hysteria  and  the  psycho- 
neuroses.  To  that  extent  such  a  patient  is  hysterical  or  psycho- 
neurotic. 

Treatment. — The  treatment  must  be  entirely  symptomatic.  A 
careful  search  should  be  made  in  each  case  for  functional  abnor- 
malities and  for  the  origin  of  mental  conflicts  and  correction  ap- 
plied as  far  as  possible. 

Many  cases  will,  of  necessity,  have  to  spend  most  of  their  lives 
in  a  hospital.  It  is  therefore  desirable  to  educate  them  as  early 
as  possible  in  good  habits.  They  should  be  encouraged  to  some 
form  of  occupation,  preferably  out  of  doors.  Under  the  influ- 
ence of  hospital  surroundings  and  farm  life  these  cases  may  get 
on  very  comfortably  and  the  deterioration  process  be  consider- 
ably retarded. 

It  seems  probable  that  one  of  the  best  methods  of  approach  to 
the  treatment  of  these  cases  would  be  by  the  method  of  reeduca- 
tion through  the  agency  of  industrial  training.     If  this  is  to  be 


DEMENTIA  PRECOX.  1 8/ 

done  intelligently,  however,  it  is  essential  that  the  patient  b€  not 
merely  put  to  work  in  a  haphazard  way,  but  that  a  sufficiently 
careful  analysis  of  the  psychology  of  his  particular  condition  be 
made  so  that  it  will  appear  what  is  the  best  method  of  approach 
to  arouse  his  interests  and  fix  his  attention.  It  is  also  necessary 
to  bear  in  mind  the  motor  disturbances,  more  especially  of  the 
catatonic  group,  because  here  the  education  will  have  to  be  ad- 
dressed more  or  less  to  restoring  certain  motor  adjustments.  The 
same  principles  are  involved  in  treatment  of  this  sort  as  have 
been  long  recognized  in  dealing  with  the  mentally  defective.  The 
avenue  of  approach  to  the  individual  must  first  be  worked  out 
before  it  can  be  expected  that  material  results  will  be  obtained. 
In  the  few  cases  that  have  been  worked  upon  in  this  hospital  along 
these  lines  the  improvement  has  been  prompt,  marked,  and  con- 
siderable. Such  improvement  is  of  course  open  to  the  criticism 
that  it  might  have  taken  place  any  way  in  the  natural  course  of 
the  disease,  and  requires  further  and  more  elaborate  studies  to 
define  its  possibilities.  The  principle  is  to  work  out  an  adjust- 
ment in  the  environment  that  will  bring  it  within  the  powers  of 
the  patient  to  adapt  to.  Psychoanalytic  investigation  is  revealing 
more  and  more  how  the  possibilities  for  treatment  may  be  defined. 

One  of  the  most  hopeful  methods  of  approach  to  this  problem 
is  by  a  study  of  the  way  in  which  recovery  has  been  brought  about 
in  those  cases  that  get  spontaneously  well.  This  may  teach  us 
how  we  can  help,  and  also,  what  is  of  equal  importance,  teach  us 
to  avoid  doing  what  will  make  matters  worse.  Bertschinger^- 
has  recently  written  illuminatingly  upon  this  subject. 

Prophylaxis. — Preventive  measures  are  dependent  upon  the 
ability  to  recognize  in  the  child  the  possibilities  of  a  future  precox. 
The  recent  studies  of  character  anomalies  as  found  in  the  anam- 
nesis of  precox  patients  indicates  the  possibility  of  foreseeing  this 
result  in  a  certain  considerable  number  of  cases,  particularly  those 
presenting  the  "  shut  in  "  type  of  personality.^^ 

The  method  of  procedure  in  such  cases  would  be  to  attempt  to 
overcome  the  defect  present  in  the  particular  case  by  educational 

22  Bertschinger :  Heilungsvorgange  bei  Schizophrenen,  Allg.  Zeits. 
Psychiat,  Bd.  68,  pp.  2.     Translated  in  Psychoanalytic  Review,  Vol.  III. 

23  Hoch,  August :  Constitutional  Factors  in  the  Dementia  Prsecox  Group, 
Rev.  of  Neurol,  and  Psych.,  Aug.,  igio. 


1 88  OUTLINES   OF   PSYCHIATRY. 

and  psychoanalytic  methods.^*  It  would  seem  that  a  recognition 
of  the  precox  character  in  the  child  would  make  it  possible  to  save 
it  from  a  number  of  stresses  that  might  prove  disintegrating 
factors.  Particularly  an  open,  healthy  initiation  into  the  mysteries 
and  problems  of  sex  is  important,  as  this  is  the  rock  upon  which 
these  cases  are  often  shipwrecked.  Protection  from  undue  stresses 
and  a  careful  education  along  lines  of  the  development  of  self- 
sufficiency  in  the  face  of  difficulties  with  a  full  appreciation  of 
the  limits  of  strength  and  adjustability  is  the  keynote. 

2*Jelliflfe,  S.  E. :  Predementia  Prsecox,  Am.  Jour.  Med.  Sci.,  1907,  p.  157. 


CHAPTER  XII. 

The  Presenile,  Senile  and  Arteriosclerotic  Psychoses. 

This  grouping  together  of  the  presenile,  the  senile,  and  the 
arteriosclerotic  psychoses  is  one  for  convenience  only.  These 
periods  of  life  present  many  and  varied  types  of  psychoses  which 
are  incapable  of  any  but  a  provisional  classification.  The  whole 
region  is  extremely  complex,  and  presents  a  very  heterogeneous 
group  of  pictures  most  difficult  to  classify. 

Two  things  stand  out,  viz.,  the  preponderance  of  depressions 
and  the  importance  of  the  physical  condition.  The  great  number 
of  depressions  is  probably  due  to  the  fact  of  a  failure  of  com- 
pensation at  the  psychological  level.  Conflicts  which  the  patients 
have  been  able  to  deal  with  effectively  during  the  up-hill  period 
of  life  break  through  and  overwhelm  them  when  the  constructive 
forces  begin  to  fail  after  middle  age.  The  association  of  vascu- 
lar changes,  as  well  as  other  tissue  changes,  with  this  period  is 
responsible  for  the  large  dependence  of  the  prognosis  on  the  phys- 
ical condition  and  the  considerable  part  played  by  defect  symp- 
toms in  the  symptomatology. 

The  Presenile  Psychoses. — This  period  is  especially  note- 
worthy because  of  the  great  prominence  of  depressions. 

Involution  Melancholia. 

The  term  melancholia  has  been  limited  to  the  depressions  of 
later  life  that  cannot  be  satisfactorily  classed  with  any  of  the 
other  psychoses,  as  for  instance  manic-depressive  psychosis. 

Etiology. — Melancholia  is  essentially  a  disease  of  the  period 
of  involution — forty  to  fifty  years  in  women,  rarely  before  fifty 
in  men.  A  considerable  number,  but  by  no  means  all,  show  the 
beginning  of  senile  decay — gray  hair  and  the  early  changes  of 
arterio-sclerosis  being  most  noticeable.  The  menopause  seems  to 
be  an  important  etiological  factor  in  women.  Heredity  does  not 
play  as  important  a  role  here  as  in  some  of  the  other  psychoses, 
being  only  present  in  about  sixty  per  cent,  of  the  cases.    Marked 


190  OUTLINES   OF   PSYCHIATRY. 

exciting  causes,  such  as  emotional  shock,  or  other  conditions  of 
mental  stress  are  unusually  frequent.  It  would  seem  that  this 
class  of  causes  operating  upon  a  mind  under  the  general  stress 
of  the  involution  period,  and  perhaps  the  additional  stress  of 
heredity,  were  the  important  factors  in  etiology. 

It  is  coming  to  be  believed  that  one  of  the  important  factors  of 
the  involution  period  is  the  atrophy  of  certain  of  the  ductless 
glands — particularly  the  uterus  and  ovaries,  the  prostate  and  tes- 
ticles, the  thyroid,  and  adrenals — and  that  certain  of  the  disturb- 
ances of  this  period  of  life  are  dependent  upon  an  unbalanced 
relationship  brought  about  at  this  time  between  these  glands.^ 

Symptomatology. — The  disease  commonly  has  a  prodromal 
period  of  several  months'  duration.  The  symptoms  of  this  period 
are  indefinite  and  are  comprised  of  certain  head  symptoms,  such 
as  pressure,  pain,  vertigo,  together  with  anorexia,  irritability,  in- 
somnia, mental  insufficiency,  a  mild  neurasthenic  state  and  some 
emaciation. 

This  condition  becomes  progressively  worse  and  the  patients 
develop  a  morbid  fear  of  impending  danger — apprehensive  de- 
pression. The  morbid  background  for  this  depression  is  not  in- 
frequently delusions  of  sin.  All  sorts  of  acts  in  the  patient's  past 
life  are  reviewed  and  considered  to  be  unforgivable  sins.  Mas- 
turbation, a  petty  theft,  the  failure  to  carry  out  the  advice  of  a 
priest,  in  fact  almost  anything  may  be  looked  upon  as  a  terrible 
sin,  even  magnified  into  the  unpardormble  sin,  and  the  patient 
fears  his  soul  is  irretrievably  lost,  that  he  will  go  to  hell  when  he 
dies  and  suffer  its  torments  eternaly. 

The  fear  and  apprehension  from  such  causes  may  be  compara- 
tively slight  and  the  patient  show  no  outward  evidences  of  it 
except  in  conversation.  Under  these  circumstances  he  is  quite 
often  able  to  put  his  depression  in  the  background  and  occupy 
himself  with  some  form  of  work.  In  these  cases  consciousness 
is  unclouded,  orientation  is  unimpaired,  and  hallucinations,  if 
present,  take  a  minor  place  in  the  symptom-complex.  In  these 
cases,  even  when  the  depression  is  considerably  marked,  the 
patients  are  quite  capable  of  seeing  a  joke  and  the  lapse  into  a 
moment  of  light  talk  and  the  smile  showing  forth  from  a  back- 

^  Remond  and  Voivenel :  Essai  sur  le  role  de  le  menopause  en  pathologie 
mentale,  L'Encephale,  Feb.,  191 1. 


PRESENILE,    SENILE   AND   ARTERIOSCLEROTIC   PSYCHOSES.        I9I 

ground  of  profound  depression  are  noteworthy  and  characteristic. 

If  the  depression  becomes  more  marked  the  fear  and  appre- 
hension graduate  into  a  condition  of  anxiety.  The  patient  goes 
about  wringing  his  hands,  moaning  and  groaning,  perhaps  repeat- 
ing over  and  over  again  some  such  phrase  as  "  Oh,  my  God !  Oh, 
my  God  !  "  "  It  is  a  fearful  thing.  Good  Lord  help  me !  "  The 
fear  of  impending  danger  is  imminent,  the  patient  is  lost  and  is 
about  to  be  executed.  Whenever  the  physician  visits  the  ward  he 
is  believed  to  have  come  to  carry  out  the  sentence  of  execution, 
and  the  patient  begs  and  pleads  to  be  spared,  not  to  be  taken  out 
and  butchered,  shot,  and  cut  up  into  little  pieces.  Reassurances 
are  in  vain.  The  slamming  of  a  door  in  an  adjoining  ward  is  the 
report  of  a  gun — a.  patient  has  just  been  shot  and  they  are  coming 
for  him.  One  patient  constantly  repeats  "  Doctor,  will  I  be  done 
away  with  tonight?"  and  "Then  will  I  be  here  tonight  just  the 
same  as  last  night,  and  will  I  be  here  tomorrow  just  the  same  as 
today?"  Another  patient  believes  herself  very  sinful,  refuses  to 
eat  because  the  food  should  be  used  for  others,  walks  about  in  an 
agitated  manner  picking  her  fingers  and  attempted  suicide  because 
she  was  afraid  she  was  to  be  put  to  death.  These  are  the  cases 
of  agitated  melancholia. 

Even  in  these  cases  consciousness  remains  unclouded,  orienta- 
tion is  little  if  at  all  impaired,  and  the  form  of  thought  is 
maintained. 

Quite  a  different  picture  is  sometimes  presented  by  patients 
with  symptoms  of  retardation.  The  milder  cases  merely  show 
slow  movements,  slow  response  to  questions  with  a  low  voice  and 
remind  one  of  the  depressive  stage  of  manic-depressive  psychosis. 
This  condition  is  not  uncommon.  More  marked  cases,  however, 
present  mutism,  inactivity  and  resistance  sufficient  to  warrant 
characterizing  them  as  stuporous.  This  condition,  however,  may 
not  be  altogether  due  to  retardation  but  may  be  the  result  of  delu- 
sions— delusional  control — to  the  effect  they  must  not  speak,  that 
it  is  wicked  to  eat,  and  the  like.  The  mental  condition  is  one  of 
intense  apprehensive  depression  with  delusions  and  often  hallu- 
cinations. The  retardation  in  these  cases  by  no  means  constitutes 
as  important  a  part  of  the  clinical  picture  as  it  does  in  manic- 
depressive  psychosis. 

A  still  further  development  of  anxiety  may  lead  to  a  condition 


192  OUTLINES  OF  PSYCHIATRY. 

of  marked  and  continuous  motor  agitation  with  insomnia,  refusal 
of  food  and  emaciation,  with  marked  clouding  of  consciousness, 
hallucinations  and  disorientation. 

Confusion. — These  are  the  most  exaggerated  of  the  cases  of 
involutional  melancholia  and  lead  rapidly  to  a  condition  of 
exhaustion. 

In  these  marked  cases  of  apprehension  and  anxiety  there  is 
quite  frequently  a  considerable  amount  of  precordial  distress  and 
tachycardia  and  often  a  sense  of  oppression  over  the  chest  with 
a  feeling  of  difficulty  of  breathing.  These  symptoms  are  apt  to 
appear  in  attacks,  at  which  times  the  mental  depression  is  most 
pronounced.  Although  suicidal  tendencies  are  frequent  in  this 
form  of  psychosis,  it  is  not  necessarily  at  these  times  that  they 
are  most  apt  to  be  exaggerated. 

Farrar  distinguishes  two  froms  of  this  psychosis  which  he 
quite  clearly  defines,  viz.,  true  melancholia  or  melancholia  vera 
and  anxiefas  prasenilis,  while  he  describes  a  third  in  which  the 
symptoms  are  not  quite  so  well  marked  but  are  rather  of  a  nega- 
tive character — depressio  apathetica. 

Melancholia  vera  in  the  main  is  an  autopsychosis.  The  de- 
lusions are  auto-accusatory,  with  ideas  of  sin  but  with  clear  con- 
sciousness ;  there  is  no  defect  of  orientation.  The  patient  believes 
his  soul  is  lost,  that  he  is  to  suffer  eternal  torment  hereafter,  and 
about  these  beliefs  there  is  no  doubt,  but  on  the  contrary  a  marked 
"  subjective  certainty."  There  may  be  some  slight  tendency  to 
somatopsychic  delusions,  insight  is  defective,  and  sHght  anxiety 
may  be  present. 

Anxietas  prasenilis,  on  the  contrary  in  the  main  is  an  allo- 
psychosis.  There  is  a  very  marked  "subjective  uncertainty" 
which  gives  an  unreal  tinge  to  the  outer  world,  and  out  of  which 
grows  the  fear  of  things  unknown,  culminating  in  the  marked 
anxiety  which  is  characteristic  of  this  form  of  the  psychosis. 
Remorse  or  dread  of  future  are  not  elements  in  the  depression ; 
on  the  contrary,  it  is  the  great  unknown  and  overwhelming  pres- 
ent that  seems  about  to  destroy  them.  These  cases  occur  later  in 
life  than  the  former,  show  more  evidences  of  senile  decay,  such 
as  arterio-sclerosis,  and  present  such  symptoms  as  verbigera- 
tion, rhythmical  movements,  suggestibility;  the  prognosis  is  less 
farorable. 


PRESENILE,   SENILE   AND  ARTERIOSCLEROTIC  PSYCHOSES.       1 93 

In  depressio  apathetica  there  is  simply  a  let-down,  a  stopping 
on  the  part  of  one  who  has  been  leading  an  active  life.  Interest 
abates,  the  struggle  is  drawn  away  from  and  we  have  a  picture 
of  mild  depression  with  clear  consciousness  and  no  disturbance 
of  orientation.  There  is  some  "  subjective  uncertainty"  delusions 
and  sensory  fabrications  play  little  part.  The  symptoms  are  nega- 
tive rather  than  positive;  the  prognosis  is  relatively  good. 

The  danger  from  suicide  is  greater  ini  this  psychosis  than  in 
any  other,  and  every  case  of  melancholia  should  be  considered 
a  potential  suicide.  One  of  the  principal  reasons  that  a  tendency 
to  suicide  is  so  dangerous  a  symptom  here  is  that  the  carrying 
of  suicidal  tendencies  into  action  is  not  interfered  with  by  retarda- 
tion in  the  way  in  which  it  is  in  manic-depressive  psychosis.  In 
manic-depressive  psychosis  the  suicidal  impulse  is  continuously 
prevented  from  expressing  itself  in  action  by  the  ever-present 
difficulty  of  the  release  of  motor  impulses,  while  here  no  such 
difficulty  maintains,  and  the  tendency  constantly  tends  to  find 
expression  in  appropriate  action. 

The  delusional  content  of  consciousness  varies  widely  in  this 
disease.  Hypochondriacal  delusions  are  quite  common  and  some- 
times we  find  nihilistic  delusions,  feeling  of  unreality,  the  patient 
claiming  that  nothing  exists,  there  are  no  people,  no  world  and 
the  like.  This  is  the  so-called  dclire  de  negation  of  the  French. 
Then,  again,  we  not  infrequently  find  that  the  delusions  take  on 
very  bizarre,  absurd,  fantastic  forms,  indicative  of  an  underlying 
defect.  This  condition  may  occur  early  in  severe  cases  or  come 
later  as  evidence  of  senile  decay.  The  same  may  be  said  of  delu- 
sions of  grandeur,  of  great  power,  and  the  like,  except  that  they 
usually  appear  later  in  the  course  of  the  malady  but  are  equally 
evidence  of  deterioration.  There  may  be  a  strange  mixture  of 
depressive  and  grandiose  ideas,  as  with  the  patient  of  Weygandt/ 
who  believed  she  was  going  to  be  roasted  in  a  silver  kettle.  The 
deterioration  and  defect  of  judgment  is  well  shown  here. 

Weygandt^  notes  the  following  list  of  delusions  that  are  found 
in  this  psychosis:  (i)  Hypochondriacal  delusions;  (2)  delusions 
of  sinfulness;  (3)  delusions  of  persecution;  (4)  delusions  of 
poverty;  (5)  ideas  of  unworthiness ;  (6)   delusions  of  explana- 

2  Weygandt,  Wilhelm :  Atlas  und  Grundriss  der  Psychiatric.  Munchen, 
J.  F.  Lehmann,  ig02. 


194  OUTLINES   OF   PSYCHIATRY. 

tion;  (7)  ideas  of  insignificance;  (8)  nihilistic  ideas;  (9)  delu- 
sions of  possession;  (10)  ideas  of  grandeur. 

Course,  Prognosis  and  Termination. — As  compared  with 
other  curable  psychoses  this  can  hardly  be  said  to  be  of  good 
prognosis.  About  forty  per  cent,  get  well.  The  remaining  sixty 
per  cent,  terminate  in  various  ways:  some  by  suicide,  some  by 
death  from  intercurrent  disease,  which  in  their  debilitated  state 
is  poorly  withstood;  some  by  death  from  general  marasmus  or 
the  development  of  tuberculosis ;  some  lapse  into  chronicity ;  and, 
finally,  a  certain  few  improve  sufficiently  to  leave  the  hospital 
and  get  on  quite  well  at  home,  though  still  somewhat  depressed. 
A  certain  number  of  this  last  class  may  get  worse  under  home 
surroundings  and  have  to  be  returned  to  the  hospital. 

This  latter  class  seem  to  get  on  quite  well  in  the  hospital,  but 
the  minute  they  attempt  to  take  up  the  cares  of  life,  to  assume  the 
worries  of  the  struggle  for  existence,  they  break  down.  Perhaps 
their  already  degenerated  vessels  cannot  adjust  themselves  to  the 
increased  demands  made  upon  them  by  a  more  active  brain. 

Unfavorable  symptoms  are  the  development  of  bizarre,  absurd 
and  grandiose  delusions  including  underlying  deterioration. 
Marked  physical  evidences  of  senility  are  also  of  poor  omen.  A 
contemporaneous  improvement  of  both  the  physical  and  mental 
conditions  is  the  most  favorable  sign. 

The  above  statement  of  the  course  and  prognosis  has  been 
thrown  very  much  in  doubt  by  the  work  of  Dreyfus.^  He  made 
a  careful  investigation,  so  far  as  possible,  of  the  life  histories  of 
the  Heidelberg  material  comprising  81  cases  in  all.  Thirty-four 
(34)  cases  were  personally  investigated.  Eight  (8)  were  not  per- 
sonally investigated,  and  39  were  deceased.  As  a  result  of  this 
study  he  concluded  that  with  the  exception  of  2  cases  undiagnosed, 
2  cases  in  which  a  mistake  in  diagnosis  had  been  made,  and  possi- 
bly 2  more  doubtful  cases,  that  all  were  cases  of  manic-depressive 
psychosis.  This  conclusion  was  reached  by  finding  the  funda- 
mental symptoms  of  this  disease  present.  Of  these  cases  66  per 
cent,  were  recovered  or  recovering  at  time  of  death,  8  per  cent, 
developed  arteriosclerosis,  25  per  cent,  died  unrecovered  of  inter- 
current disease  or  suicide. 

3  Dreyfus,  Georges  L. :  Die  Melancholie ;  ein  Zustandsbild  des  manisch- 
depressiven  Irreseins.    Jena,  Gustav  Fischer,  1907. 


PRESENILE,    SENILE   AND   ARTERIOSCLEROTIC   PSYCHOSES.       1 95 

Even  admitting  all  these  facts  it  would  seem  that  the  involution 
period,  the  age  factor,  colors  the  picture  materially  and  Dreyfus 
himself  admits  the  involution  cases  as  a  sub-species  of  the  manic- 
depressive  group.  There  seems  certainly  to  be  a  greater  number 
of  depressions  at  this  time  of  life  and  if  they  are  manic-depressive 
depressions  the  attacks  are  longer  and  more  severe.  They  seem 
also  more  frequently  to  take  on  the  mixed  type. 

Many  psychiatrists  still  believe,  although  Kraepelin  himself 
accepts  Dreyfus'  conclusions,  that  there  is  still  a  place  for  invo- 
lution melancholia  distinct  from  the  manic-depressive  group. 

Pathology. — There  is  very  little  special  pathology  of  this  dis- 
ease. An  increased  neuroglia  formation  in  the  deeper  layers  of 
the  cortex  has  been  described  and  in  this  disease  we  find  most 
often  as  a  mode  of  termination  that  condition  of  central  neuritis 
described  by  Meyer.*  The  symptoms  of  this  condition  are  the 
sudden  development  of  contractions  with  evidences  of  degenera- 
tion in  the  motor  tracts,  emaciation,  retraction  of  lips  from  teeth, 
low  temperature,  semi-coma  and  death. 

Interpretation  of  the  Psychosis. 

The  reason  why  depressions  are  so  prevalent  in  later  life  is  due 
to  the  failure  of  repression  and  of  the  compensatory  devices. 
Complexes  which  have  been  adequately  handled  during  the  earlier 
years  begin  to  create  more  trouble  as  the  individual  passes  the 
height  of  mental  strength — ^they  become  relatively  stronger  be- 
cause the  forces  opposed  to  them  become  weaker.  The  depres- 
sions of  later  life  then  are  largely  the  result  of  conflicts  of  which 
the  individual  has  been  the  host  for  many  years  but  which  only 
produce  a  psychosis  upon  the  failure  of  repression  as  he  grows 
older. 

Treatment. — The  foremost  consideration  in  a  great  number  of 
these  cases  is  the  prevention  of  suicide.  This  will  require  con- 
stant surveillance  both  night  and  day  and  in  cases  where  the 
suicidal  tendency  is  at  all  developed  it  is  rarely  justifiable  to 
attempt  this  treatment  at  home,  as  only  in  an  institution  is  the 
problem  of  taking  care  of  this  class  of  patients  appreciated  at  its 
true  value. 

*  Meyer,  Adolf :  On  Parenchymatous  Systemic  Degenerations  mainly  in 
the  Central  Nervous  System,  Brain,  Part  XCIII,  1901. 


196  OUTLINES  OF   PSYCHIATRY. 

Insomnia  is  a  frequent  symptom  for  which  the  usual  hypnotics, 
paraldehyde,  sulfonal,  trional  and  chloralamid  are  useful.  In 
cases  with  high  tension  an  occasional  exhibition  of  chloral  may 
be  of  advantage.  Artificial  feeding  often  has  to  be  resorted  to,  as 
refusal  of  food  is  common.  This  means  should  not  be  left  as  a 
last  resort  but  begun  promptly  as  soon  as  the  patient  shows  the 
results  of  malnutrition,  as  this  class  of  cases  require  supporting 
treatment  much  more  than  cases  developing  at  an  earlier  age.  If 
the  apprehension  and  anxiety  are  very  marked  and  associated  with 
much  motor  agitation  and  restlessness,  opium  may  be  tried — pref- 
erably the  Tr.  Opii  deod.  This  will  usually  relieve  the  mental 
distress,  but  because  of  the  tendency  to  acquire  the  opium  habit 
and  the  chronicity  of  these  cases,  this  treatment  is  hardly  justi- 
fiable except  to  tide  over  some  exceptional  access  of  anxious 
depression. 

In  such  cases  of  extreme  agitation,  hydrotherapeutic  measures 
are  the  best  means  for  quieting  the  patient — the  hot  pack  and 
more  especially  the  continuous  warm  bath,  the  patient  being  placed 
in  a  tub  of  water  at  about  98°  F.  and  left  in  several  hours,  often 
all  day  each  day  and  in  some  cases  continuously  for  days  at  a 
time. 

Differential  Diagnosis. — The  principal  disease  which  has  to  be 
differentiated  is  manic-depressive  psychosis.  Enough  has  already 
been  said  on  this  point,  except  to  note  that  the  occurrence  of 
previous  attacks  should  be  looked  into.  They  would,  of  course, 
make  for  a  diagnosis  of  manic-depressive  psychosis,  although  if 
the  history  of  these  cases  is  carefully  searched  there  will  be  found 
evidences  of  affect  fluctuations  as  might  be  expected  from  what 
has  been  said  of  its  relation  to  the  manic-depressive  group. 

Early  senile  psychoses  are  often  hard  to  differentiate  and  in 
fact  the  two  graduate  into  one  another.  Old  cases  of  melan- 
cholia often  get  to  present  evidences  of  senile  decay.  Arterio- 
sclerosis seems  to  bridge  the  space  between  the  two  sets  of  psy- 
choses, the  involutional  and  the  senile,  and  so  we  find  symptoms 
common  to  both. 

The  Senile  Psychoses. 

A  certain  degree  of  involution,  regression,  failure  of  both  the 
mental  and  physical  powers  is  normal  to  man  if  he  lives  beyond 
the  period  of  his  maximum  vigor.    Age,  however,  is  not  a  mat- 


PRESENILE,    SENILE   AND   ARTERIOSCLEROTIC   PSYCHOSES.       1 9/ 

ter  of  years.  Some  men  are  older  at  forty  than  others  are  at 
sixty,  and  the  dictum  that  states  that  "  a  man  is  as  old  as  his 
arteries  "  comes  very  near  the  truth. 

Causes. — The  causes  of  the  senile  and  presenile  psychoses  lie  in 
the  tissue  changes  incident  to  involution.  These  changes  begin 
much  earlier  in  some  persons  than  in  others  and  in  them  the  ele- 
ment of  heredity  probably  enters  as  a  potent  factor.  A  tendency 
to  early  arterial  degeneration  certainly  occurs  in  families.  This 
tendency  may,  of  course,  be  aggravated  and  the  changes  of  senile 
degeneration  hastened  by  a  variety  of  causes,  both  mental  and 
physical,  among  which  alcoholism  is  perhaps  the  most  prominent. 
Symptomatology. — When  senile  involution  begins  earlier  than 
the  sixtieth  year  there  exists  the  condition  spoken  of  as  senium 
precox.  Bleuler^  believes  these  cases  are  cases  of  late  dementia 
precox.  The  symptoms  of  this  condition  differ  usually  from  those 
of  simple  senile  involution  or  even  from  the  more  common  types 
a  senile  dementia  developing  later,  and,  as  it  were,  form  a  con- 
necting link  between  the  cases  of  involution  melancholia  and  the 
senile  psychoses.  The  condition  has  a  rather  long  prodromal 
period,  during  which  the  patient  complains  of  all  sorts  of  sensa- 
tions, such  as  vertigo,  general  malaise  and  various  paresthesias 
not  unlike  the  beginning  symptoms  of  involution  melancholia. 
At  the  same  time  he  becomes  morose,  seclusive  and  irritable. 
From  this  condition  delusions  soon  develop  which  are  hypochon- 
driacal and  persecutory  in  character.  These  delusions,  however, 
being  founded  upon  a  basis  of  deterioration  partake  of  and  show 
the  element  of  defect  in  their  absurdity.  The  brain  is  dried  up, 
certain  viscera  have  been  removed,  bones  are  broken  and  like 
complaints  are  heard.  The  persecutory  delusions  may  take  the 
usual  form  of  poisoning  and  the  like,  but  are  apt  to  take  on  a 
sexual  type  and  wife  or  husband  believes  their  partner  to  be 
unfaithful.  These  delusions  remind  one  of  the  similar  delusions 
found  in  chronic  alcoholism,  but  they  are  much  more  absurd  and 
built  upon  the  most  inconsequential  happenings,  often  originating 
entirely  in  the  patient's  mind.  One  not  infrequently  sees,  for  in- 
stance, a  wife  complaining  of  the  infidelity  and  sexual  dissipa- 
tions of  a  husband  who  is  so  old  and  feeble  that  he  can  hardly 
get  about.  These  patients  may  be  very  irritable  at  times  and 
become  very  angry  as  a  result  of  what  they  believe  to  be  going 
•Bleuler:  Dementia  Prsecox  oder  Gruppe  der  Schizophrenien.    191 1. 


198  OUTLINES  OF  PSYCHIATRY. 

on,  but  they  usually  soon  quiet  down  and  go  right  on  living  quietly 
and  peacefully  under  the  same  conditions,  making  no  effort  to 
correct  them  until  the  next  outbreak  occurs.  Their  mental  defect 
is  shown  in  these  evidences  of  lack  of  judgment  as  well  as  in  the 
absurdity  of  their  delusions. 

Consciousness  is  unclouded  and  the  patients  are  well  oriented. 
Emotionally  there  is  often  some  depression,  while  in  the  attacks 
of  rage  the  emotion  of  anger  occupies  the  foreground.  Halluci- 
nations are  not  prominent  but  may  occur. 

The  more  usual  symptoms  of  senile  involution  occurring  after 
sixty  are  in  the  main  a  loss  of  memory  for  recent  events,  due  to 
lack  of  impressibility  to  the  extent  even  that  events  of  only  an 
hour  before  are  completely  forgotten,  lack  of  ability  to  recognize 
faces,  marked  egotism,  so  that  others'  wants  and  comforts  are 
not  considered,  which  may  be  associated  with  some  irritability  on 
interference.  There  is  developed  more  and  more  as  the  years 
go  on  a  true  misoneism,  so  that  the  patient  will  positively  not 
tolerate  any  change  in  the  usual  order  of  things,  everything  must 
be  done  the  same  from  day  to  day,  the  same  seat  is  preempted,  a 
particular  kind  of  food  demanded,  and  the  like  with  other  com- 
forts. With  this  misoneism  and  the  lack  of  memory  for  recent 
events  goes  a  marked  tendency  to  reminiscence.  The  events  of 
youth  and  the  years  long  past,  unlike  those  of  recent  occurrence, 
are  vividly  recalled  and  the  patient  thus  really  lives  in  a  world 
of  former  days,  constantly  recalling  and  reiterating  things  that 
occurred  long  ago.  This  condition  becomes  progressively  worse, 
the  patient  leading  a  vegetative  existence  almost  wholly,  no  mental 
initiative,  failure  of  judgment  and  a  progressive  loss  of  compre- 
hension of  the  environment,  so  that  there  is  no  adequate  grasp  of 
the  present  at  all. 

With  this  mental  failure  goes  a  corresponding  change  on  the 
physical  side.  The  signs  oi  age  are  evident  in  the  wasted  muscles, 
the  wrinkled,  inelastic  skin,  gray  hair,  the  raucous  voice,  arcus 
senilis,  senile  cutaneous  affections,  and  signs  of  arteriosclerosis 
in  the  superficial  arteries.  In  this  connection  it  should  be  remem- 
bered that  the  condition  of  the  palpable  arteries  may  not  indicate 
at  all  the  condition  of  the  cerebral  vessels.  The  superficial  ves- 
sels may  show  marked  arteriosclerotic  changes,  while  the  cerebral 
vessels  are  in  relatively  good  condition,  or,  on  the  contrary,  the 


PRESENILE,   SENILE  AND  ARTERIOSCLEROTIC  PSYCHOSES.       1 99 

cerebral  vessels  may  be  seriously  affected  in  a  person  whose 
radials  are  comparatively  soft  and  whose  temporals  are  not  notice- 
ably tortuous.  '     ■  •' 

This  condition  of  senile  decay  may  be  said  to  be  normal, 
although  many  persons  live  to  advanced  years  without  showing 
it — it  is  the  condition  of  the  dotard.  It  is,  nevertheless,  properly 
speaking,  a  true  dementia. 

If  upon  this  background  of  dementia  active  psychotic  symptoms 
are  developed  they  are  usually  shown  in  delusions,  with  perhaps 
hallucinations.  The  delusions  are  of  a  persecutory  character  and 
the  condition  may  be  spoken  of  as  paranoid.  They  are  not,  how- 
ever, as  fixed  as  in  paranoia  and  because  of  the  dementia  there  can 
be  little  effort  at  systematization.  The  emotional  attitude  varies 
with  the  content  of  the  delusion  but  is  often  marked  by  its  silly, 
childish  characteristics.  Thus  one  old  lady  says  she  has  a  great 
deal  of  money  but  does  not  know  how  much — it  is  in  the  Court  of 
Claims  and  her  daughter  is  coming  to  take  her  home  and  then  they 
will  get  the  money.  This  is  all  told  in  the  most  matter  of  fact 
way,  repeated  as  though  it  were  a  formula  and  not  a  vital,  living 
fact  of  her  life.  This  attitude  and  emotional  poverty  show  fully 
as  well  as  the  absurdity  of  the  delusions  the  demented  foundation 
of  the  psychosis. 

Alzheimer^  has  described  a  presenile  dementia,  developing 
about  the  fourth  decade,  which  has  the  pathology  of  senile  de- 
mentia and  clinically  manifests  focal  symptoms  particularly  of 
the  paraphasic  and  apraxic  variety. 

Senile  dements  are  especially  apt  to  be  restless  and  suffer  from 
insomnia,  sleeping,  on  the  contrary,  much  of  the  time  during  the 
day,  even  as  they  sit  up  in  their  chairs.  Often  the  restlessness 
at  night  takes  the  form  of  wandering  about  the  house  and  during 
these  periods  they  are  apt  to  be  disoriented  considerably  and  to 

"  Alzheimer :  "Ober  eine  eigenartige  Erkrankung  der  Hirnrinde  {27  Ver- 
sammlung  siidwest  deutscher  Irrenartze),  Ref.  Centrb.  fur  Nervenheilk. 
und  Psych.,  Vol.  30,  1907;  Uber  eigenartige  Krankheitsfalle  des  spateren 
Alters,  Zeit.  f.  gesamte  Neurol,  u.  Psych.,  Vol.  4,  191 1.  Perusiin:  t)ber 
klinisch  und  histologisch  eigenartige  psychische  Erkrankung  des  spateren 
Lebensalters,  Histol.  u.  histopath.  Arbeiten  iiber  die  Grosshirnrinde  von 
Nissl  und  Alzheimer,  Vol.  3,  1910.  Lafora:  Beitrag  zur  Kenntnis  der 
Alzheimer'schen  Krankheit  oder  presenilen  Demenz  mit  Herdsymptomen, 
Zeitsch.  f.  d.  gesamte  Neurol,  und  Psychiat.,  Vol.  6,  191 1. 


200  OUTLINES   OF   PSYCHIATRY. 

show  much  confusion.  This  tendency  to  confusion  is,  too,  often 
marked  when  the  patient  awakes  from  a  sleep,  for  some  time  he 
fails  to  apprehend  his  environment,  does  not  know  where  he  is, 
or  what  time  of  day  it  is.  It  is  as  though  the  cerebral  circulation, 
because  perhaps  of  the  diseased  vessels,  took  a  very  long  time  to 
readjust  itself  to  the  waking  state. 

This  form  of  senile  dementia  is  spoken  of  as  simple  senile 
deterioration. 

Aside  from  these  attacks  the  patient  may  be  quite  well  oriented 
and  there  may  be  no  clouding  of  consciousness.  On  the  other 
hand  they  may  be  disoriented,  both  as  to  time  and  place.  This 
is  often  largely  due  to  their  memory  defect,  lack  of  attention  and 
impressibility.  Such  patients  will  supply  deficiencies  in  their 
memory  by  all  sorts  of  fabrications,  reminding  one  of  the  similar 
symptoms  in  paresis  and  certain  alcoholic  cases  (Korsakow's 
psychosis).  One  old  man,  although  just  out  of  bed  and  so  feeble 
he  can  hardly  stand  up,  tells  me  he  has  been  working,  making  some 
sort  of  wire  affair,  for  a  man  on  Harrison  Street  for  the  past 
seven  months.  Another  patient  tells  me  she  cannot  sleep  nights, 
for  somebody  spends  the  entire  night  shooting  her  and  fills  her 
with  bullets,  yet  while  telling  this  she  shows  no  disturbance  what- 
ever, wears  a  slight  smile  and  talks  of  these  events  as  if  they  were 
the  most  commonplace  affairs  of  everyday  life.  These  are  the 
cases  of  presbyophrenia  which  quite  closely  resembles  Korsakow's 
psychosis. 

To  those  cases  in  which  the  symptoms  of  confusion,  which  we 
have  seen  already  occurring  in  the  form  of  senile  deterioration 
just  described,  especially  connected  with  changes  in  cerebral 
circulation,  present  much  more  prominently,  in  which  there  is 
marked  disorientation  and  clouding  of  consciousness,  the  desig- 
nation of  senile  confusion  is  given. 

In  these  cases  the  confusion  is  not  merely  a  transitory  symp- 
tom, occurring  upon  awakening,  but  is  constant.  These  patients 
do  not  know  where  they  are,  will  ask  if  dinner  is  ready  when 
perhaps  five  minutes  before  they  have  eaten  a  hearty  meal,  forget 
the  location  of  their  room,  undress  and  go  to  bed  in  the  middle 
of  the  day,  no  longer  recognize  those  about  them,  not  even  their 
children,  and  are  difiicult  to  manage,  headstrong,  peevish,  resistive 
and  inaccessible  to  reason.    Various  delusions  may  be  expressed, 


PRESENILE,   SENILE  AND  ARTERIOSCLEROTIC  PSYCHOSES.       20I 

often  hypochondriacal  in  character,  but  quite  characteristically 
absurd  in  content. 

This  variety  of  senile  dementia  often  follows  that  of  simple 
deterioration,  being  in  fact  but  a  more  pronounced  grade  of  de- 
generation.    In  severe  cases  it  may  usher  in  the  mental  changes. 

Certain  cases,  over  sixty  years  of  age,  develop  a  true  paranoid 
condition,  with  delusions  of  persecution  and  hallucinations  of 
hearing.  These  cases  may  not  present  marked  evidences  of  senile 
decay  and  consciousness  may  be  unclouded,  orientation  complete 
and  the  train  of  thought  well  maintained.  This  condition  must 
be  differentiated  from  an  alcoholic  delusional  psychosis,  paranoia 
and  dementia  precox  which  Kraepelin  says  may  rarely  develop 
at  advanced  age. 

Among  the  physical  symptoms  that  may  develop  in  the  course 
of  senile  deterioration  are  apoplexy,  apoplectiform  attacks  and 
senile  epilepsy.  True  apoplexy  may,  of  course,  occur  and  com- 
plicate the  picture  while  apoplectiform  attacks  resulting  in  tran- 
sient paralyses,  and  reminding  one  of  the  similar  attacks  in  paresis 
are  not  uncommon.  Epileptic  seizures  may  take  the  form  of 
either  petit  mal  or  grand  nml,  and  well  developed  attacks  which 
recur  with  considerable  frequency  are  not  uncommonly  developed 
in  the  senile.  Chorea,  of  the  type  of  Huntington,  or  of  the  post- 
apoplectic variety,  is  not  infrequently  observed  in  large  institu- 
tions for  the  insane. 

In  an  analysis  of  two  hundred  cases  of  senile  dementia  Pickett' 
gives  the  following  list  of  symptoms  which  he  found  and  which  I 
reproduce  in  the  order  of  their  relative  frequency:  Wandering 
street;  hallucinations  prominent;  violence;  vertigo;  persecutory 
ideas,  other  than  poisoning,  conspiracy,  etc. ;  exaltation ;  night 
prowling;  apoplectiform  strokes;  headache;  suicidal  attempts; 
suspicion  of  conspiracy;  suspicion  of  poisoning;  violence  at  night; 
epileptiform  attacks;  delusions  of  marital  infidelity;  setting  fire  to 
things;  echolalia;  chorea. 

In  addition  to  the  types  of  cases  already  discussed  a  senile 
delirium  has  been  described.  This  condition  is  characterized  by 
varied  and  fleeting  delusions,  multiform  hallucinations,  clouding 

''  Pickett,  William :  Senile  Dementia :  A  Clinical  Study  of  Two  Hundred 
Cases  with  Particular  Regard  to  Types  of  the  Disease,  Jour.  Nerv.  and 
Ment.  Dis.,  Feb.,  1904. 

14 


202  OUTLINES   OF  PSYCHIATRY. 

of  consciousness,  great  incoherence  and  marked  motor  restless- 
ness, often  an  occupation  delirium.  This  may  usher  in  a  case 
that  has  been  up  to  that  time  following  a  normal  course,  or  it 
may  occur  as  an  episode  in  any  case  of  senile  psychosis.  As  in 
the  condition  of  acute  delirious  mania,  so  here  I  think  it  should 
usually  be  attributed  to  some  bodily  cause — pneumonia,  nephritis, 
cystitis.  It  may  clear  up  but  is  frequently  fatal,  and  in  these 
cases  it  is  not  improbable  that  the  delirium  is  a  manifestation  of 
a  terminal  infection. 

Course  and  Prognosis. — The  course  of  senile  dementia  is  pro- 
gressive until  death.  The  patients  finally  become  completely  de- 
mented, so  that  they  are  wholly  disoriented,  confused,  know  no 
one  around  them ;  in  fact  may  not  even  know  their  own  name. 

It  is  quite  possible  to  have  attacks  of  other  psychoses  at  this 
time  of  life,  particularly  stages  of  manic-depressive  psychosis. 
The  prognosis  of  the  psychosis  is  not  changed  materially  by  the 
senium  except  of  course  that  exhaustion  is  more  apt  to  occur  and 
terminate  the  case.  The  underlying  dementia  continues  the  same 
or  perhaps  is  somewhat  worse  after  the  attack  passes  off.  The 
senile  deterioration,  being  due  to  actual  tissue  changes,  remains 
stationary  or  gets  progressively  worse,  while  the  psychosis  en- 
grafted upon  it  may  or  may  not  be  recovered  from. 

Diagnosis. — Paranoia  must  be  differentiated  by  the  history. 
Many  cases  of  paranoia  develop  senile  deterioration  but  the  his- 
tory would  show  an  early  development  of  symptoms. 

It  should  be  remembered  that  catatonic  symptoms  occur  in  the 
senile  psychoses  and  not  for  that  reason  alone  suppose  the  patient 
to  be  an  old  precox. 

The  cases  with  well-marked  arteriosclerosis  and  multiple  areas 
of  softening  present  a  picture  closely  resembling  paresis.  A 
careful  study  of  the  reflexes,  both  pupillary  and  tendinous,  a  con- 
sideration of  the  speech  defect  which  is  more  truly  aphasic,  and 
the  age  of  the  patient,  with  evidences  of  arteriosclerosis,  but 
without  evidences  of  syphilis,  will  usually  serve  to  make  the 
distinction. 

There  are  certain  borderland  cases  presenting  emotional  de- 
pressions that  are  difficult  to  distinguish  from  involution  melan- 
cholia. The  presence  of  defect  is  the  criterion  to  judge  by,  though 
these  two  conditions  do  undoubtedly  graduate  into  one  another 


PRESENILE,   SENILE  AND  ARTERIOSCLEROTIC  PSYCHOSES.       203 

and  as  already  stated  melancholiacs  after  a  prolonged  duration 
may  develop  senile  deterioration. 

Considerable  difficulty  may  arise  in  distinguishing  presbyo- 
phrenia from  Korsakow's  psychosis.  Nouet®  has  recently  made  a 
careful  differential  study  of  the  two  conditions.  He  sets  forth 
the  following  diagnostic  considerations: 

Korsakow's  psychosis  affects  persons  particularly  of  adult  age ; 
presbyophrenia,  on  the  contrary,  belongs  to  the  period  of  old  age, 
the  age  of  predilection  oscillating  about  seventy  years.  Presbyo- 
phrenia, it  is  known,  is  quite  uniquely  an  affection  of  women,  while 
Korsakow's  psychosis  is  far  from  being  rare  among  men.  The 
humor  of  the  presbyophrenic  is  always  gay,  euphoric  and  satisfied, 
quite  different  from  the  psychopolyneuritic,  who  is  ordinarily  de- 
pressed or  apathetic,  and  whose  face  preserves  an  invariable  im- 
mobility. The  traits  of  the  presbyophrenic  are  extreme  mobility, 
they  laugh,  make  grimaces  in  which  the  mimic  muscles  partici- 
pate. The  facies  of  the  psychopolyneuritics,  however,  are  always 
dull  and  without  expression.  Loquacity  is  a  symptom  scarcely 
ever  lacking  in  presbyophrenia ;  the  patients  talk  without  stopping 
about  everything,  with  equal  volubility.  This  symptom  is  lack- 
ing in  Korsakow's  psychosis.  The  presbyophrenic  is  polite,  ami- 
able and  cordial,  characteristics  which  one  seeks  in  vain  among 
the  psychopolyneuritics.  Disorders  of  consciousness  are  much 
more  marked  in  the  presbyophrenic.  These  patients  have  no  un- 
derstanding of  their  state  of  illness  and  content  themselves  with 
laughing  when  one  asks  a  question  relative  to  their  physical  or 
mental  health.  On  the  contrary  the  psychopolyneuritic  gives  a 
fairly  good  account  of  himself  and  of  his  position,  and  is  the  first 
to  lament  his  situation.  The  judgment  of  these  patients,  even  in 
the  chronic  forms,  is  less  noticeably  affected,  and  their  degree  of 
intellectual  enfeeblement  less  marked.  The  amnesia,  finally,  is 
more  profound  in  the  presbyophrenic,  and  besides  in  this  affection 
the  patient  does  not  possess  at  all  a  knowledge  of  this  amnesia — 
the  inverse  of  what  one  observes  in  the  chronic  forms  of  Korsa- 
kow's disease,  where  the  subjects  speak  spontaneously  to  their 
interlocutors  of  the  profound  troubles  of  their  memory.  Presbyo- 
phrenia is  rare  in  its  typical  forms,  but  common  in  the  formes 
frustes.     Where  the  symptoms  only  approach,  or  where  certain 

8  Nouet :     Presbyophrenie    de    Wernicke    et    Les    Psychopolyneurites, 
L'Encephale,  Feb.  10,  191 1. 


204  OUTLINES   OF   PSYCHIATRY. 

of  them  are  lacking,  the  presbyophrenia  has,  perhaps,  the  dis- 
tinctive characteristics  of  arteriosclerosis,  which  are  seen  much 
more  among  these  patients  than  among  simple  senile  dements. 
Patients  die  nearly  always  of  cerebral  hemorrhages,  and  their 
nervous  centers  present  at  autopsy  pronounced  atheromatous 
lesions. 

Pathology. — Grossly  the  brain  shows  signs  of  atrophy  and 
decreased  weight.  The  dura  may  be  adherent  to  the  calvarium 
and  may  present  internal  hemorrhagic  pachymeningitis.  The  pac- 
chionian granulations  are  increased  in  size.  The  leptomeninges 
are  thickened,  especially  the  pia,  which  is  turbid  from  lymph 
exudate.  The  sub-arachnoid  space  is  filled  with  fluid,  which 
takes  the  place  of  the  atrophied  convolutions — hydrocephalus  ex 
vacuo.  The  convolutions  are  shrunken  and  the  fissures  between 
them  widened.  The  blood  vessels  may  or  may  not  show  the 
changes  of  arteriosclerosis,  there  may  be  thrombosis,  or  the  lumen 
of  some  of  the  smaller  ones  may  be  very  greatly  reduced,  thus 
impairing  the  nutrition  of  the  area,  to  which  they  are  distributed. 
Miliary  aneurisms  may  occur  and  hemorrhage  from  rupture  of 
them  is  not  infrequent.  Multiple  areas  of  softening  may  be  pres- 
ent from  these  various  sources,  more  especially  in  the  cortex. 

Microscopically  the  cells  show  degenerative  changes,  especially 
an  increase  in  yellow  pigment  amounting  to  a  pigmentary  degen- 
eration. There  is  also  a  disappearance  of  fibers,  especially  the 
tangential.  These  having  association  functions  their  disappear- 
ance accounts  in  a  measure  for  the  dementia.  The  neuroglia  is 
increased  and  scleosis  of  the  cortex  is  commonly  found. 

There  is  a  pure  senile  atrophy  which  is  not  associated  with 
arteriosclerosis.  In  this  condition  there  is  a  diffuse  atrophy  of  the 
nervous  parenchyma  with  increase  of  neuroglia  but  the  vessels 
show  nothing.  In  this  condition  Redlich^  has  described  certain 
small  patches — miliary  necroses — which  are  not  softenings  and 
not  associated  in  any  way  with  the  vessels.     Fischer^"  has  shown 

"  Redlich :  Ueber  miliaren  Sklerosen  der  Hirnrinde  bei  seniler  Atrophic, 
Jahrb.  f.  Psych,  u.  Neurol.,  Bd.  XVII,  1898. 

10  Fischer :  Miliare  Nekrosen  mit  driingen  Wucherungen  der  Neuro- 
fibrillen,  eine  regelmassige  Veranderung  der  Hirnrinde  bei  seniler  Demenz, 
Monatschr.  f.  Psych,  u.  Neurol.,  Bd.  XXII.  Der  Histopathologic  der 
Presbyophrenic,  Jahresvers.  d.  Deutscher  Ver.  f.  Psych,  zu  Berlin,  24-25, 
April,  1908;  Rcf.  Allg.  Ztsch.  f.  Psych.,  Bd.  LXV,  p.  500. 


PRESENILE,    SENILE   AND   ARTERIOSCLEROTIC   PSYCHOSES.      20$ 

that  the  axis  cylinders  in  these  patches  show  peculiar  gland-like 
enlargements  which  he  thinks  specific  of  the  pathology  of  presbyo- 
phrenia. 

There  have  been  described  by  various  authors  basket-like  neu- 
roglia structures  surrounding  the  ganglion  cells.  These  neuroglia 
and  satellite  basket  formations  and  ganglion  cell  incrustations 
have  been  well  described  by  Achucarro." 

Aside  from  these  changes  other  organs  are  usually  found 
affected,  particularly  the  heart  and  kidneys,  the  former  showing 
degenerative  changes  in  the  myocardium,  the  latter  evidences  of 
chronic  nephritis. 

Treatment. — The  mild  cases,  especially  those  that  maintain 
their  orientation  fairly  well,  can  be  cared  for  at  home.  Those 
with  marked  confusion,  especially  with  a  tendency  to  wandering, 
need  an  attendant  to  be  with  them.  There  is  danger  of  their 
becoming  lost  and  coming  to  grief,  or  if  they  wander  about  the 
house  at  night  they  are  apt  to  meet  with  some  accident,  more 
often  to  fall  down  stairs  and  sustain  fractures.  Patients  who 
are  very  resistive,  present  surgical  troubles,  are  filthy  in  habits, 
or  show  a  tendency  to  commit  sexual  crimes,  should  be  cared  for 
in  an  institution. 

As  regards  the  more  special  treatment,  little  is  to  be  said. 
Hygienic  surroundings,  a  simple  diet,  looking  after  the  emunc- 
tories,  and  if  insomnia  is  present  the  occasional  exhibition  of  a 
hypnotic  constitutes  about  all  there  is  to  be  done.  In  this  class 
of  cases,  more  perhaps  than  in  any  other,  is  the  use  of  alcohol  as 
a  hypnotic  indicated.  A  little  whiskey  and  hot  water,  or  a  glass 
of  beer  or  ale  acts  very  nicely.  It  should  be  given,  however, 
strictly  under  medical  authority  and  supervision,  as  these  patients 
are  apt  to  be  susceptible  to  its  influences.  In  the  earlier  stages 
of  the  disease  potassium  iodide  is  the  drug  par  excellence  for  its 
general  alterative  properties  and  its  effect  on  the  arterial  tension. 

The  Epochal  Psychoses  in  General. 

In  the  past  it  has  been  common  to  describe  certain  other  psy- 
choses occurring  at  physiological  epochs  and  to  give  them  the 
name  of  the  epoch  during  which  they  occurred.     Thus  we  find 

11  Achucarro,  Nicolas :  Some  Pathological  Findings  in  the  Neuroglia  and 
in  the  Ganglion  Cells  of  the  Cortex  in  Senile  Conditions.  Bulletin  No.  2, 
Govt.  Hosp.  for  the  Insane,  1910, 


206  OUTLINES   OF   PSYCHIATRY. 

the  group  of  puerperal  psychoses,  especially  puerperal  mania,  and 
the  lactational  psychoses. 

Infection  and  exhaustion  are  frequent  causes  operating  at  these 
periods  to  produce  mental  disturbances.  A  large  number  of  these 
psychoses  therefore  naturally  group  themselves  under  the  infec- 
tion-exhaustion types  to  be  described  in  the  next  chapter.  Psy- 
chogenic factors,  however,  are  frequently  of  prime  importance. 
A  depression  during  pregnancy,  for  example,  may  mean  that  the 
wife  is  not  in  love  with  her  husband  and  therefore  does  not  want 
his  child.  It  will  be  understood,  however,  that  the  strains  incident 
to  pregnancy,  parturition,  the  puerperium  and  lactation  may  pro- 
duce outbreaks  of  various  psychoses,  particularly  dementia 
precox.  There  is  no  such  thing,  for  example,  as  a  puerperal  psy- 
chosis, strictly  speaking.  Mental  disorder  frequently  occurs  dur- 
ing the  puerperium  but  must  be  classified  in  accordance  with  the 
symptoms  it  presents  rather  than  the  time  at  which  it  occurs. 

The  Arteriosclerotic  Psychoses. 

Arteriosclerosis. — This  condition  is  associated  with  a  progress- 
ive failure  of  the  mental  faculties  and  local  symptoms,  due  to 
areas  of  softening.  Because  of  the  diffuseness  of  the  lesions  the 
picture  often  closely  resembles  paresis,  but  the  patient  is  much 
further  advanced  in  years  than  is  usual  for  the  paretic.  Cerebral 
arteriosclerosis  furnishes  the  connecting  link  between  the  psy- 
choses of  involution  and  of  the  senium.  Many  of  the  late  depres- 
sions present  the  picture  of  beginning  senility,  and  in  general  the 
later  the  depressions  come  on  the  worse  the  prognosis,  while  many 
of  these  cases  drift  over  into  a  senile,  or  arteriosclerotic  dementia. 

In  the  anamnesis  alcohol,  syphilis  and  hard  mental  work  may 
be  found.  It  is  therefore  important  in  those  cases  resembling 
paresis  to  examine  the  cerebrospinal  fluid  both  as  to  the  nature 
of  the  cell  content  and  its  reaction  to  the  Wassermann  complement 
fixation  test. 

Alzheimer^^  has  described  four  varieties  of  the  disease  which 
are  to  an  extent  differentiated  clinically. 

12  Alzheimer :  Histol.  u.  histopat.  Arb.,  Bd.  I,  1904.  Allg.  Ztschr.  f. 
Psych.,  LI,  LIII,  and  LIX,  Die  Seelenstorungen  auf  arteriosclerotischer 
Grundlage,  Allg.  Zeitschr.  f.  Psych.,  Vol.  59,  cited  by  Barret,  Albert  M. : 
A  Study  of  Mental  Disease  Associated  with  Cerebral  Arterio-Sclerosis, 
Am.  Jour.  Insanity,  July,  1905. 


PRESENILE,    SENILE   AND   ARTERIOSCLEROTIC   PSYCHOSES.       20/ 

1.  Arteriosclerotic  Brain  Atrophy. — This  occurs  in  two  forms, 
a  mild  form  with  severe  arterial  sclerosis  but  an  absence  of  focal 
brain  lesions.  The  symptoms  are  easy  fatigue,  slight  failure  of 
memory,  dizziness  and  headache.  The  severe  type  may  resemble 
the  mild  at  first  but  is  progressive,  leads  to  profound  dementia 
and  presents  in  its  course  apoplectiform  and  epileptiform  attacks 
and  focal  symptoms. 

2.  Subcortical  encephalitis  of  Binswanger.^^  In  this  condition 
the  white  matter  is  largely  involved  as  a  result  of  the  disease  in 
the  long  medullary  arteries.  Apoplectiform  and  epileptiform 
attacks  occur  and  also  transitory  attacks  of  confusion,  aphasia 
and  paresis,  disturbances  suggesting  focal  lesions.  Focal  lesions 
are  not  found  extensively  but  areas  of  softening  often  occur  in 
the  basal  ganglia. 

3.  Perivascular  Gliosis. — In  this  condition  there  is  a  disappear- 
ance of  nervous  elements  about  the  diseased  vessels  and  replace- 
ment by  neuroglia. 

4.  Senile  Cortical  Devastation. — Here  are  found  extensive  de- 
struction of  cortical  areas  in  the  vascular  territories  of  the 
diseased  vessels. 

PiCK^*  has  very  thoroughly  described  certain  large  atrophies 
involving  whole  lobes  or  portions  of  lobes.  The  occipital  lobes 
may  be  involved,  producing  blindness,  or  the  temporal,  producing 
deafness,  for  example.  The  atrophy,  however,  does  not  always 
follow  a  vascular  area  and,  while  it  is  generally  supposed  to  be 
due  to  arteriosclerotic  disturbances  in  the  irrigation  of  these 
territories,  the  cause  is  not  always  altogether  clear. 

Symptomatology. — Some  of  the  cases  develop  only  nervous 
symptoms,  irritability,  forgetfulness,  hypochondriacal  ideas  or 
perhaps  ideas  with  a  paranoid  trend,  but  remain  in  a  practically 
stationary  condition  for  a  long  time.  Other  cases  are  progressive, 
with  epileptiform  seizures,  the  development  of  focal  symptoms, 
and  an  advancing  dementia  that  becomes  profound. 

*'  Binswanger :  Die  Begrenzung  der  Allgemeinen  Paralyse,  AUg.  Zeitschr. 
f.  Psych.,  Vol.  51.    Cited  by  Barrett,  loc.  cit. 

1*  Pick :  Zur  Symptomatologie  der  linkseitigen  Schlafenlappen  atrophic, 
Monatschr.  f.  Psychiat.  u.  Neurol.,  Vol.  16,  1904.  Pick:  Die  umschriebene 
senile  Hirnatrophie  als  Gegenstand  klinischer  und  anatomischer  Forschung, 
Arbeiten  aus  der  deutsch.  psych.  Klinik  in  Prag,  Berlin,  1908. 


208  OUTLINES   OF   PSYCHIATRY. 

Diagnosis. — The  disease  most  apt  to  be  confounded  with  arterio- 
sclerotic dementia  is  paresis.  It  is  extremely  difficult  to  differ- 
entiate many  cases  of  paresis  with  focal  lesions.  In  general 
paresis  occurs  earlier  in  life  and  presents  more  uniform  impair- 
ment. In  arteriosclerotic  dementia  the  patient  has  better  insight 
into  his  condition,  the  delusions  are  more  closely  related  to  his 
previous  life,  to  the  vocation  and  social  position  of  the  patient, 
they  are  less  unnatural,  the  "  nucleus  of  the  personality  "^^  is 
better  retained.  The  disease  commonly  lasts  much  longer  than 
paresis. 

The  focal  lesions  may  give  rise  to  a  mistaken  diagnosis  of  brain 
tumor. 

Arteriosclerosis  and  the  involution  of  the  senium  are  so  closely 
associated  that  it  is  often  practically  impossible  to  separate  them 
clinically.  A  careful  anamnesis  and  neurological  examination  is 
important  in  every  case.  It  must  not  be  forgotten  that  many 
cases  with  localized  brain  lesions,  aphasics  and  even  apraxics 
pass  for  dements  though  analysis  may  show  a  comparatively  clear 
intelligence. 

Treatment. — In  the  main  the  treatment  should  be  to  so  regulate 
the  life  as  to  take  all  unnecessary  strain  from  the  cardiovascular 
system.  Easily  assimilated  food,  care  of  the  emunctories,  moder- 
ate exercise,  freedom  from  worry  and  from  mental  or  physical 
exertion.  For  the  insomnia  alcohol  in  the  form  of  a  small  dose 
of  whiskey  and  water  at  night  is  excellent,  but  should  be  given 
with  great  care  and  its  administration  carefully  guarded,  as  these 
patients  are  especially  susceptible  to  it  and  often  develop  periods 
of  confusion  from  very  small  doses. 

15  Weber,  L.  W. :  Zur  Klinik  der  arteriosklerotischen  Seelenstorungen, 
Monatschr.  f.  Psych,  u.  Neurol.,  Bd.  XXIII,  1908. 


CHAPTER  XIII. 

The  Infection-Exhaustion  Psychoses, 

The  infection  and  exhaustion  psychoses  are  classified  together 
in  this  chapter  partly  because  of  the  closely  similar  pictures  their 
respective  psychoses  present  and  partly  because  of  the  fact  that 
the  two  conditions  are  so  closely  and  so  frequently  found  asso- 
ciated clinically.  It  would  be  difficult,  for  example,  to  discrimi- 
nate the  two  factors  in  a  post-partum  case  where  there  had  been 
infection  following  a  prolonged  and  difficult  labor  with  consid- 
erable hemorrhage.  Then,  again,  it  is  probable  that  the  imme- 
diate causes  are  not  altogether  dissimilar  in  the  two  conditions, 
as  it  seems  to  be  fairly  well  demonstrated  that  the  symptoms  of 
fatigue  are  due  to  a  toxemia,  the  result  of  the  development  of 
poisonous  substances  in  the  body  from  the  chemical  breaking 
down  of  tissue. 

In  this  chapter  it  will  be  necessary  to  frequently  use  the  terms 
confusion  and  delirium.  By  confusion  is  meant  a  state  of  dis- 
orientation in  all  the  three  spheres — temporal,  spatial  and  per- 
sonal. The  confusion  and  consequent  disorientation  may  be  of 
any  degree.  By  delirium  is  meant  a  confused  and  clouded  state 
of  consciousness  associated  with  and  symptomatic  of  fever.  The 
two  terms  are  not  clearly  differentiated,  as  we  speak  of  pre- 
febrile  delirium. 

Previous  chapters  have  emphasized  the  fact  that  the  condition 
of  permanent  mental  impairment — dementia — modified  the  symp- 
toms of  a  psychosis,  so,  for  example,  if  there  was  a  delusional 
state,  the  delusions  tended  more  to  take  on  strange,  bizarre, 
fantastic  characters,  because  of  the  lack  of  judgment  and  of  the 
critical  faculty.  What  has  been  said  in  this  respect  of  the  per- 
manent mental  impairment  of  dementia  may  be  as  well  said  of 
the  more  acute,  transitory  states  of  mental  impairment — confu- 
sion and  delirium.  In  these  conditions  with  disorientation  and 
clouding  of  consciousness  the  judgment  is  also  greatly  impaired 
and  the  critical  faculty  practically  in  abeyance.     As  a  result,  here 

209 


210  OUTLINES   OF  PSYCHIATRY. 

also  the  most  fantastic  delusions  are  present.  The  delusions, 
however,  are  less  apt  to  have  any  fixity  because  of  the  multiplicity 
and  changeableness  of  the  symptoms  in  the  psychosensory  field 
on  which  they  are  largely  dependent.  Here,  as  elsewhere,  the 
specific  character  of  the  delusional  and  hallucinatory  experiences 
is  psychologically  determined.  Not  infrequently  upon  recovery 
the  patient  can  give  the  explanation  of  their  meanings. 

Pre-Febrile,  Febrile  and  Post-Febrile  Psychoses. 

Speaking  generally  fever  and  infection  may  be  said  to  be  meas- 
ures of  the  mental  stability  of  an  individual.  While  some  persons 
will  remain  mentally  clear  with  a  fever  of  io6°  F.,  others  will 
become  delirious  with  only  a  slight  rise  in  temperature.  Some 
persons  will  go  through  an  attack  of  typhoid,  for  instance,  with 
little  or  no  delirium,  while  in  other  cases  delirium  is  an  early 
symptom  and  continues  throughout  the  course  of  the  disease. 
The  lack  of  resistance  is  sometimes  very  marked  indeed.  I  recall 
a  young  man  who  developed  marked  symptoms  as  a  result  of  a 
very  slight  infection  of  a  finger.  There  was  only  a  drop  or  two 
of  pus,  no  ascending  lymphangitis  and  only  about  a  degree  of 
temperature,  yet  resistance  was  so  poor  that  he  was  tempo- 
rarily deranged.  In  general,  these  cases  are  of  poorer  prognosis 
than  the  more  resistive.  It  is  generally  considered,  for  instance, 
that  the  early  development  of  delirium  in  typhoid  is  a  bad  sign, 
indicating  that  the  nervous  system  is  seriously  involved  and  that 
the  case  is  going  to  be  a  severe  one. 

Infection  Delirium. — Under  this  head  are  included  the  mental 
disturbances  which  develop  early  in  the  infectious  diseases,  either 
before  the  fever  appears  at  all  or  else  when  it  is  still  so  low  that 
the  mental  disturbance  cannot  be  attributed  to  it  and  therefore 
must  be  due  solely  to  the  infectious  agent — (initial  delirium). 
This  condition  is  found  associated  with  typhoid,  typhus,  smallpox, 
malaria  and  hydrophobia.  It  usually  takes  the  form  of  an  acute 
confusion,  but  there  may  be  delusions  of  a  consistently  disagree- 
able character,  generally  persecutory.  The  condition  in  hydro- 
phobia is  rather  one  of  change  of  character,  irritability,  and  great 
sensitiveness  to  sensory  impressions,  restlessness,  usually  depres- 
sion, verging  into  a  delirium  with  confusion,  hallucinations,  appre- 
hensiveness  and  excitement  as  the  disease  progresses,  with  which 


THE   INFECTION-EXHAUSTION    PSYCHOSES.  211 

is  usually  mixed  many  symptoms  of  psychogenic  origin.  In 
those  cases  especially  in  which  the  delirium  is  a  very  early  symp- 
tom, occurring  before  the  fever,  the  diagnosis  is  very  difficult  and 
may  be  quite  impossible  until  the  infectious  disease  is  frankly 
established. 

Febrile  Delirium. — A  condition  tending  to  confusion  of  vari- 
able intensity,  usually  following  in  its  degrees  the  febrile  move- 
ment. The  milder  cases  usually  exhibit  symptoms  only  as  night 
approaches. 

It  may  be  described  in  four  stages  according  to  the  degree  of 
severity.  In  the  first  stage:  headache,  irritability,  sensitiveness 
to  noises  and  light,  restlessness,  disturbing  dreams.  In  the  second 
stage  hallucinations  appear,  especially  in  the  visual  field.  The 
hallucinations  are  of  a  dream-hke  character  and  the  patient  may 
still  be  made  to  react  clearly.  In  the  third  stage  the  motor  dis- 
turbance is  greater  and  takes  on  the  character  of  jactitation.  The 
third  stage:  profound  dulling  of  consciousness,  uncertain  and 
ataxic  movements,  coma  and  death. 

The  onset  and  severity  of  the  delirium  is,  to  an  extent,  a  meas- 
ure of  the  mental  stability  of  the  patient.  Delirium  develops 
much  more  readily  in  the  unstable  and  those  predisposed  to  the 
development  of  psychotic  symptoms. 

BoNHOEFFER^  describes  several  forms  of  fever  delirium.  An 
epileptiform  excitement  and  an  infectious  dream  state  (Ziehen), 
an  hallucinosis,  and  hallucinatory,  catatonic,  and  incoherent  con- 
fusional  states. 

Post-Febrile  Psychoses. — These  conditions  either  develop  as 
a  result  of  the  delirium  of  the  febrile  state,  continuing  after  the 
fever  has  subsided,  or  may  take  their  origin  from  the  first  during 
the  post-febrile  period.  In  the  latter  case  the  disease  is  essen- 
tially an  exhaustion  psychosis. 

In  this  period  also  we  may  have  epileptiform  excitements  and 
dream  states.  Bonhoeffer^  calls  attention  to  the  fact  that  there 
may  also  be  a  retrospective  falsification  of  memory  that  gives 
somewhat  the  appearance  of  Koraskow's  psychosis. 

iBonhoeffer:  Die  symptomatischen  Psychosen  im  Gefolge  von  akuten 
Infektionen  und  inneren  Erkrankungen.  Pub.  by  Deuticke,  Leipzig  und 
Wien,  1910. 

2  Bonhoeffer :  Die  symptomatischen  Psychosen. 


212  OUTLINES   OF  PSYCHIATRY. 

The  mental  state  during  defervescence  is  usually  one  of  con- 
fusion, with  multiform  hallucinations — the  patient  sees  strange 
faces  peering  at  him  from  the  pictures  on  the  wall,  he  can  see 
through  the  walls  into  the  next  house,  the  pictures  turn  about  and 
change  places — there  is  a  marked  disorientation  and  delusions 
usually  of  a  persecutory  nature — poison  is  administered  in  the 
medicine.  This  condition  may  become  more  severe,  the  delirium 
more  active,  the  utterances  very  incoherent  and  finally  a  stuporous 
state  may  develop  with  a  tendency  to  catalepsy.  Grandiose  ideas 
may  also  occur  at  this  time. 

The  exhaustion  in  most  of  these  cases  may  be  profound  and 
terminate  fatally;  a  certain  few  go  on  to  the  development  of  a 
chronic  delusional  state.  Improvement  in  the  general  physical 
state  is  accompanied  by  mental  improvement. 

Exhaustion  Psychoses. 

These  conditions  develop  after  severe  exhaustion  from  any 
cause — loss  of  blood,  parturition,  prolonged  anxiety  and  worry, 
severe  mental  shock,  prolonged  convalescence  from  the  acute 
fevers,  such  as  typhoid,  pneumonia,  the  exanthemata,  etc. 

Collapse  Delirium. — This  is  the  delirium  grave  or  the  acute 
delirious  mania  of  the  older  authors. 

The  disease  may  present  a  prodromal  period  of  restless  irrita- 
bility and  insomnia,  after  which  a  condition  of  confusion  develops 
which  may  be  very  mild,  constituting  only  a  slight  degree  of  per- 
plexity or  more  usually  manifesting  hallucinations,  clouding  of 
consciousness,  disorientation  and  dreamy  delusions.  Psychomotor 
excitement  is  common,  the  patient  being  very  active  and  inclined 
to  acts  of  violence  and  destructiveness. 

The  degree  of  excitement  in  these  cases  may  become  very  great 
indeed,  in  fact  exceeding  anything  we  see  in  the  other  psychoses. 
When  this  extreme  form  was  the  only  one  recognized  the  disease 
was  supposed  to  have  a  uniformly  fatal  termination. 

In  these  severe  cases  the  incoherence  becomes  absolute,  dis- 
orientation complete,  clouding  of  consciousness  profound.  Tem- 
perature usually  develops  and  may  be  very  high — io6°.  Gastro- 
intestinal symptoms  are  common,  there  is  almost  complete  ano- 
rexia, coated  tongue,  a  frothy,  ofifensive  diarrhea,  a  high  grade  of 
indicanuria  and  great  emaciation,  a  severe  grade  of  exhaustion. 


THE   INFECTION-EXHAUSTION   PSYCHOSES.  21  3 

with  typhoid  symptoms  followed  in  a  large  proportion  of  cases 
by  coma  and  death. 

Stupor  with  catalepsy  may  constitute  an  episode  or  be  suffi- 
ciently in  evidence  to  give  its  character  to  the  attack. 

Though  the  severe  cases  almost  all  die,  the  milder  cases  usually 
make  good  recoveries.  Of  all  cases,  perhaps  fifty  per  cent,  are 
fatal. 

Many  of  these  cases  show  at  autopsy  some  acute  disease,  such 
as  pneumonia,  nephritis,  that  accounts  for  the  symptoms.  It  is, 
of  course,  readily  seen  how  difficult  the  diagnosis  of  conditions 
dependent  on  careful  physical  examination  must  be  in  these  wildly 
excited  cases. 

These  cases  have  a  short  duration,  ending  in  recovery  or  death 
in  a  few  days  or  at  most  a  few  weeks. 

Acute  Haliuclnatory  Confusion. — This  psychosis  is  less  acute 
than  the  former  but  of  the  same  general  nature,  and  may  be 
described  as  an  acute  primary  psychosis,  characterized  by  cloud- 
ing of  consciousness,  confusion,  multiform  and  usually  fleeting 
hallucinations  in  the  various  sensory  areas,  changing  delusions, 
the  emotional  attitude  being  variable  and  in  general  corresponding 
to  the  content  of  the  delusions.  It  may  be  of  considerable  dura- 
tion, often  many  months.  The  course  is  somewhat  irregular  and 
not  infrequently  interrupted  by  lucid  intervals  which  may  be  of 
only  a  few  minutes'  duration  or  may  last  a  day  or  two.  This  is 
important  to  know,  so  that  a  lucid  interval  will  not  be  definitely 
stated  to  be  the  beginning  of  permanent  recovery. 

As  in  the  preceding  form,  stuporous  states  may  intervene  and 
for  a  considerable  time  dominate  the  picture. 

Course. — Bonhoeffer^  describes  as  occurring  late  in  the  course 
of  the  infection  psychoses  certain  hyper  esthetic-emotional  states 
of  weakness,  amnesic  states,  resembling  the  Korsakow  syndrome, 
the  collapse  delirium  just  described,  and  a  meningitic  type  leading 
to  coma  and  death. 

Diagnosis. — The  diagnosis  is  to  be  made  in  general  from  the 
association  of  acute  confusion,  multiform  hallucinations,  change- 
able delusions,  disorientation,  clouding  of  consciousness  and  vari- 
able emotional  reactions,  with  specific  infection,  or  coupled  with 
the  physical  signs  of  exhaustion,  great  emaciation  and  fever.     It 

3  Bonhoeffer :  Die  symptomatischen  Psychosen. 


214  OUTLINES  OF   PSYCHIATRY. 

must  not  be  forgotten  that  certain  other  psychoses,  particularly 
dementia  precox  and  manic-depressive  psychosis,  may  originate 
under  the  same  conditions  which  lead  to  the  development  of  the 
infection-exhaustion  psychoses,  and  further,  that  aside  from  the 
condition  of  confusion  described  (primary  confusion) ,  states  of 
infection  and  exhaustion  may  complicate  any  psychosis  producing 
a  confusion  engrafted  on  the  original  mental  disorder  (secondary 
confusion).  Recurring  attacks  of  confusion  should  cause  us  to 
consider  the  possibihty  of  some  other  psychosis. 

Special  care  should  be  exercised  in  excluding  delirium  tremens 
and  epileptic  dream  states.  The  characteristic  hallucinations  of 
delirium  tremens  are  not  present,  while  the  anamnesis  or  scars 
about  the  head  and  face  will  indicate  the  presence  of  epilepsy. 

Catatonic  excitement  is  not  accompanied  by  the  signs  of  such 
great  exhaustion  or  by  such  marked  emaciation. 

It  will  be  seen,  in  general,  that  during  the  course  of  an  infection- 
exhaustion  psychosis  symptoms  may  arise  that  closely  simulate 
other  conditions.  It  may  be  necessary  to  defer  making  a  final 
diagnosis  for  a  considerable  time.  Because  of  the  frequency  with 
which  such  psychoses  as  dementia  precox  arise  as  a  result  of  acute 
illness  one  should  be  very  guarded  in  the  diagnosis  and  prognosis 
until  the  situation  fully  warrants  definite  statements. 

Treatment. — The  treatment  must,  of  course,  where  a  specific 
disease  such  as  typhoid  is  present,  be  in  the  main  the  treatment 
of  the  underlying  disease.  Otherwise  the  treatment  is  supporting 
and  sedative. 

For  the  excitement  the  continuous  bath  or  wet  pack  with  the 
occasional  exhibition  of  a  hypnotic. 

Forced  feeding  should  be  begun  as  soon  as  the  patient  begins 
to  refuse  food,  as  these  cases  have  no  strength  to  spare  for  the 
experiment  of  waiting  to  see  whether  they  will  eat. 

The  gastric  disturbance  in  many  of  these  cases  is  so  marked 
that  if  the  usual  feeding  is  given  it  will  be  promptly  vomited. 
Such  cases  should  be  fed  small  amounts  often. 

In  the  extreme  exhaustion  of  the  later  stages  hypodermoclysis 
may  be  used  with  beneficial  results. 

In  a  recently  developed  theory  Stoddart*  accounts  for  the  symp- 

*  Stoddart,  W.  H.  B. :  A  Theory  of  the  Toxic  and  Exhaustive  Psychoses, 
Jour.  Ment.  Sci.,  July,  1910. 


THE   INFECTION-EXHAUSTION    PSYCHOSES.  215 

tomatology  by  the  dissociation  of  the  neurones.  He  call  attention 
to  certain  symptoms  of  defect.  On  the  psychological  side  defects 
in  perception  and  on  the  neurological  side  anesthesia.  These  de- 
fects are  brought  about  he  thinks  by  dissociation  due  to  heightened 
resistances  at  the  neuronic  synapses.  He  recommends  strychnine 
on  the  principle  of  its  action  in  lessening  synaptic  resistance. 


CHAPTER   XIV. 

The  Toxic  Psychoses. 

Toxins  may  be  classified  on  the  basis  of  whether  they  originate 
within  the  body — endogenous — or  are  introduced  from  without — 
exogenous.  The  former  are  often  spoken  of  as  auto-toxins  and 
the  conditions  resuhing  from  them  as  auto-toxic  states  or  as  auto- 
intoxications. 

The  psychoses  resulting  from  endogenous  toxins,  dependent  as 
they  are  upon  various  bodily  diseases,  will  be  discussed  in  the 
chapter  on  the  symptomatic  psychoses. 

Alcohol. 

The  role  that  alcohol  plays  in  the  production  of  psychoses, 
while  admittedly  an  important  one,  is  not  fully  understood.  Re- 
cent^ statistics,  conservatively  interpreted,  would  indicate  that 
about  12  per  cent,  of  the  insane  confined  in  public  institutions  in 
the  United  States  are  there  because  of  its  influence,  direct  or 
indirect.  When,  however,  the  multitudinous  ways  in  which  alco- 
hol may  enter  as  a  factor  in  the  production  of  mental  disease  and 
the  far-reaching  eflfects  it  produces  are  considered  it  is  readily 
seen  that  no  statistical  study  can  begin  to  fathom  the  problem. 

While  the  psychoses  considered  under  this  heading  seem  to  be 
closely  associated  with  alcohol  and  in  the  main  present  fairly 
constant  and  characteristic  pictures,  it  must  not  be  forgotten  that 
alcohol  may  enter  as  an  etiological  factor  in  the  production  of 
symptoms  ordinarily  considered  to  be  quite  distinct  from  the 
alcoholic  psychoses  properly  so-called,  such  as  the  manic-de- 
pressive and  dementia  precox  psychoses,  while  it  is  considered 
by  some  to  be  a  very  important  causative  factor  in  paresis. 

When  attacks  of  these  psychoses  are  brought  about  by  alcoholic 
indulgence  it  is  probable  that  they  are  considerably  modified  as 
a  result  and  present  a  somewhat  atypical  picture. 

1  The  Physiological  Aspect  of  the  Liquor  Problem.  Edited  by  John  S. 
Billings,  Boston  and  New  York:  Houghton,  Mifflin  &  Co.,  1903. 

216 


THE  TOXIC   PSYCHOSES.  21/ 

That  the  psychoses  produced  as  the  result  of  abuse  of  alcohol 
are  dependent,  in  the  last  analysis,  upon  something  besides  the 
alcohol,  namely,  upon  some  peculiarity  of  make-up  of  the  indi- 
vidual, is  well  shown  by  the  fact  that,  while  a  history  of  abuse  of 
alcohol  is  frequent  in  cases  admitted  to  hospitals  for  the  insane, 
it  is  very  rare  to  find  at  autopsy,  what  in  general  hospitals  is  con- 
sidered so  typical  of  alcoholism,  namely,  cirrhosis  of  the  liver.^ 
This  means  that  the  locus  minoris  resistentice  in  these  cases  was 
the  brain  and  that  mental  disease  supervened  before  the  liver  was 
so  deeply  involved. 

Psychology. — Alcohol  has  long  been  supposed  to  be  a  stimu- 
lant. Such  supposition,  however,  was  based  largely  upon  false 
interpretations  of  subjecitve  experiences.  For  example,  one  feels 
rested  from  fatigue  by  a  small  dose  of  alcohol.  The  rested  feel- 
ing was  supposed  to  be  due  to  stimulation.  On  the  contrary,  it 
is  due  to  inhibition  of  the  sensory  channels  conveying  the  sense 
impressions  that  make  up  the  feeling  of  fatigue. 

It  has  long  been  supposed  that  small  doses  of  alcohol  produced 
an  increase  in  the  power  of  muscular  work  and  an  increase  in 
efficiency  in  the  performing  of  simple  mental  tasks.  This  stimu- 
lation was  supposed  to  continue  for  twenty  minutes  to  one  half 
hour.  The  recent  work  of  Rivers  and  Webber^  indicate  that 
such  small  doses  produce  no  effect  whatever.  If  they  are  correct 
alcohol  then  remains  a  depressant  and  paralyzant  from  the  first 
without  any  effects  of  stimulation  whatever. 

The  types  of  persons  who  drink  and  the  reasons  for  drinking 
are  many  and  varied.  While  there  are  certain  social  factors  in- 
volved, the  more  important  of  the  conditions  lie  in  the  make-up 
of  the  individual. 

First  there  are  the  individuals  for  whom  the  drinking  is  the 
expression  of  a  psychosis  and  in  no  wise  its  cause.  Here  are 
found  especially  the  early  cases  of  paresis  and  the  mild  cases  of 
manic-depressive  psychosis.  The  alcoholic  symptoms  may  com- 
pletely cloud  the  picture  for  some  time. 

2Mott,  F.  W. :  The  Psychoses  of  Chronic  Alcoholism.  Compte  Rendu 
des  Travaux  du  i*""  Congres  International  de  Psychiatrie,  de  Neurologic, 
de  Psychologic  et  de  I'Assistance  de  alienes.  Amsterdam,  2  a  7  Sept., 
1907. 

2  Rivers  and  Webber :  The  Influence  of  Small  Doses  of  Alcohol  on  the 
Capacity  for  Manual  Work,  British  Jour,  of  Psychol.,  Jan.,  1908. 

15 


2l8  OUTLINES  OF   PSYCHIATRY. 

Secondly  there  is  a  considerable  group,  to  which  belong  those 
who  drink  "  to  drown  their  troubles,"  who  attempt  to  escape  from 
reality  by  introducing  a  veil  between  it  and  them,  by  making  them- 
selves less  accessible  to  the  world  of  reality  by  dulling  their  sen- 
sorium.  These  cases  are  comprised  of  hysterics  and  members  of 
that  large  group  of  psychoneurotics.  It  should  be  remembered 
that  the  expressions  of  their  difficulties  are  often  periodic  and  that 
it  is  generally  upon  such  a  groundwork  that  dipsomania  is  found. 

Thirdly  there  is  a  considerable  group  who  are  especially  sus- 
ceptible to  alcohol  and  although  not  consuming  large  quantities 
manifest  an  exaggerated  reaction  to  small  doses.  Here  are  found 
especially  the  post-traumatic  constitution — cases  following  head 
injury  and  sunstroke — and  arteriosclerotic  and  senile  cases. 
These  are  the  unresistive  types,  and  alcohol,  like  fever,  serves  as 
a  measure  of  their  resistance  and  stability. 

Fourthly  alcoholism  enters  into,  complicates,  and  modifies  the 
picture  of  other  psychoses,  particularly  dementia  precox.  Not 
infrequently  precox  cases  are  supposed  to  be  alcoholic  in  their 
early  stages  because  of  the  promience  of  the  alcoholic  features. 

Finally  there  are  a  certain  number  of  purely  alcoholic  psy- 
choses— that  is  psychoses  dependent  upon  alcohol  per  se.  Of 
these  psychoses  those  clearly  dependent  upon  the  effects  of  alcohol 
are  the  acute  states  of  intoxication,  including  pathological  drunk- 
enness, while  delirium  tremens,  alcoholic  hallucinosis,  Korsakow's 
psychosis,  and  the  chronic  alcoholic  psychoses  generally  are  de- 
pendent upon  long  indulgence  in  the  poison.  Whether  they  are 
directly  the  further  expression  of  chronic  alcoholism  or  are  in 
some  way  dependent  upon  the  secondary  elaboration  of  toxins,  the 
result  of  disordered  nutrition,  they  certainly  need  something  be- 
sides the  simple  ingestion  of  a  toxic  dose  of  alcohol.  Kraepelin 
proposes  to  call  them,  after  the  manner  of  the  psychoses  due  to 
syphilis,  the  meta-alcoholic  psychoses. 

Drunkenness. — Alcohol,  like  fever,  may  be  said  to  be  a  meas- 
ure of  cerebral  resistance,  the  unstable,  predisposed  individual 
becoming  intoxicated  much  more  readily  than  the  average. 

The  phenomena  of  drunkenness  are,  from  the  first,  phenomena 
of  paralysis.  In  the  early  stages  it  is  only  the  higher  psychic 
functions,  which  are  largely  inhibitive,  that  are  afifected,  so  we 
get  apparent  stimulation  in  the  excitement  produced  with  flight  of 


THE  TOXIC   PSYCHOSES.  2 1 9 

ideas,  pressure  of  activity,  loss  of  the  sense  of  propriety,  degra- 
dation of  the  moral  tone  and  loss  of  power  of  voluntar}'-  atten- 
tion. The  lower  centers  then  become  paralyzed  and  then  appears 
muscular  incoordination,  manifesting  itself  first  in  the  hands  and 
facial  muscles  and  the  muscles  controlling  articulation,  the  speech 
becomes  thick  and  the  gait  unsteady.  Sensory  disturbances  ap- 
pear, such  as  diplopia,  tinnitus  aurium,  and  the  senses  of  touch 
and  pain  are  blunted.  If  the  paralyzing  action  of  the  alcohol 
continues  coma  results,  which  may  be  fatal.  The  mood  during 
intoxication  may  be  a  pleasant  one,  and  frequently  is  one  of 
boisterous  exaltation,  constituting  the  exalted  type;  on  the  other 
hand,  a  sad,  depressive,  lachrymose  mood  may  prevail,  constituting 
the  depressed  type. 

Pathological  Drunkenness. — Among  certain  predisposed  indi- 
viduals alcohol  produces  unusual  and  much  more  severe  symp- 
toms. In  this  condition  hallucinations  and  delusions  are  found 
dominating  the  field  of  consciousness,  the  delusions  being  usually 
of  a  persecutory  character.  In  other  cases  the  excitement  may 
issue  in  a  wild  maniacal  frenzy  or  the  depression  may  be  so  pro- 
found as  to  result  in  attempts  at  suicide.  In  some  persons  the 
paralyzing  effects  of  alcohol  are  unusually  pronounced  and  coma 
appears  early  on  the  scene.  Those  who  have  latent  hysterical 
tendencies  may  have  hysterical  attacks  during  intoxication,  while 
alcohol  frequently  produces  convulsions  in  epileptics.  Aside  from 
this  latter  action,  however,  the  convulsive  properties  of  alcohol 
alone  are  capable  of  producing  convulsions  in  persons  who  have 
long  indulged  and  are  profoundly  degenerated,  though  some  claim 
such  persons  must  be  of  epileptogenic  make-up. 

In  these  cases  of  pathological  drunkenness  in  which  the  reaction 
to  alcohol  is  so  pronounced  it  is  quite  common  to  find  amnesia  for 
periods  of  profound  intoxication. 

Delirium  Tremens. — This  disorder  usually  occurs  as  the  result 
of  a  prolonged  drunken  debauch  in  a  chronic  alcoholic,  during 
which  the  patient  has  had  insufficient  food  and  rest.  According 
to  some  authors,  it  may  result  directly  from  the  withdrawal  of 
alcohol.  It  may,  however,  appear  in  the  moderate  but  continuous 
drinker  as  the  result  of  a  single  excess  following  a  traumatism  or 
as  the  initial  symptom  of  an  acute  illness. 

The  whole  question  of  the  occurrence  of  an  abstinence  delirium 


220  OUTLINES    OF   PSYCHIATRY. 

is  a  mooted  one.  The  recent  researches  of  Holitscher*  on  this 
point  are  illuminating.  The  conclusion  appears  to  indicate  that 
abstinence  delirium,  if  it  occurs  at  all,  is  extremely  rare.  Care 
must  be  taken  in  reaching  a  conclusion  to  eliminate,  as  possible 
causes,  wounds,  infectious  diseases,  psychic  shocks,  operations, 
etc.  It  must  be  remembered  also  that  in  many  cases  the  delirium 
has  had  a  prodromal  period  of  a  number  of  days,  and  that  one 
of  the  symptoms  of  this  period  is  a  disgust  for  liquor.  The  de- 
lirium, therefore,  occurs  in  spite  of,  not  because  of,  abstinence. 
The  disease  may  appear  suddenly,  but  there  is  generally  a  pro- 
dromal period  during  which  the  patient  is  nervous,  with  coated 
tongue,  suffering  from  anorexia,  restlessness,  tremulousness,  dis- 
turbed sleep  and  insomnia.  This  condition  rapidly  advances  with 
the  onset  of  the  attack,  the  characteristic  symptoms  of  which  are 
rapidly  developed.     They  are  tremor,  delirium  and  albuminuria. 

The  tremor  involves  more  particularly  the  small  muscles  of  the 
hand,  face  and  tongue,  but  may  also  affect  the  entire  muscula- 
ture. It  is  increased  by  muscular  tension,  such  as  forcibly  spread- 
ing the  fingers  apart. 

The  delirium  is  an  acute  hallucinatory  confusion. 

Disorientation  is  often  quite  complete,  the  patient,  although 
perhaps  fastened  in  bed,  believing  himself  in  his  office  or  home, 
surrounded  by  familiar  faces.  The  predominating  hallucinations 
are  visual  and  characteristically  take  on  the  form  of  animals. 
The  patient  sees  all  sorts  of  horrible  creatures,  snakes,  rats,  mice, 
alligators,  etc.,  which  are  uniformly  in  motion.  Surrounded  by 
the  loathsome  creatures  and  by  horribly  grimacing  faces,  terrified 
by  screams  and  shrieks  (auditory  hallucinations),  he  presents  a 
picture  of  abject  terror.  In  addition  to  these  symptoms,  the 
patient  may  complain  that  insects  or  worms  are  crawling  under 
his  skin  (paresthesia)  and  mistake  spots  upon  the  bed  or  walls 
for  bugs,  mice,  etc.  (illusions).  At  the  height  of  his  excitement 
the  patient  is  in  constant  motion,  picking  insects  from  'his  night- 
dress, repelling  the  approach  of  terrible  animals ;  in  the  extreme 
frenzy  of  his  fright,  he  may  make  murderous  assaults  on  those 
about  him,  believing  them  to  be  his  enemies,  or  perhaps  attempt 
his  own  life  to  escape  from  his  horrible  surroundings.     During 

*  Holitscher :  Zur  Frage  von  den  Abstinenzdelirien,  Psychiat.  Neurol. 
Wochen.,  Nos.  14,  15,  16,  17,  1908. 


THE   TOXIC    PSYCHOSES.  221 

all  this  time  the  patient  is  constantly  talking,  shrieking  in  fear  at 
times,  at  others  carrying  on  an  incoherent  discourse  with  imagi- 
nary persons,  fragments  of  which  often  relate  to  his  former  occu- 
pation and  friends. 

The  character  of  the  delirious  experiences  varies  greatly.  One 
patient  left  the  house  in  his  night  clothes  and  went  a  distance  of 
several  miles  attired  thus  to  the  house  of  his  sister.  On  reaching 
there  he  told  them  that  his  father  and  some  Chinamen  were  going 
to  kill  him.  Another  patient  came  to  the  hospital  with  the  his- 
tory that  he  suddenly  became  disturbed  one  night  and  told  his 
wife  that  he  saw  a  troop  of  darkies  dancing  in  his  bedroom ;  they 
appeared  to  be  rehearsing  a  play ;  he  saw  a  strange  man  of  giant 
stature  jump  off  his  bookcase  into  his  wife's  bed.  He  tried  to 
chase  these  strangers  from  the  room,  and  as  they  vanished  he 
could  see  the  skirts  of  the  women  and  the  heels  of  the  men 
flitting  past  the  doors ;  they  would  invariably  return ;  their  faces 
mocking  him. 

Some  patients  do  not  present  this  picture  of  extreme  restless- 
ness and  the  pressure  of  activity  is  not  communicated  to  such  a 
degree  to  the  function  of  speech.  Such  patients  may  present  an 
alert  appearance,  be  fairly  calm  and  can  often  be  taken  in  the 
lecture  room  before  the  class. 

The  mood,  too,  may  be  quite  different ;  from  being  in  a  condi- 
tion of  constant  apprehension  and  fear  of  an  overwhelming  and 
terrifying  environment,  they  may  be  calm,  interested  and  amused 
by  their  delirious  experiences.  The  patient  just  cited  on  his 
second  day  in  the  hospital  was  highly  entertained  by  the  appear- 
ance in  the  ward  of  a  man  with  a  monkey's  body  walking  along 
the  floor  in  a  barrel,  the  bottom  of  which  had  been  knocked  out. 
Then  there  was  the  "  human  ironing  board."  This  was  a  man's 
head  nailed  to  an  ironing  board  on  wheels ;  the  man  spit  tobacco 
juice  about  the  floor  and  water  squirted  from  his  eyes.  The 
patient  was  much  amused  by  these  experiences  and  told  the  doctor 
how  he  loved  to  lie  in  bed  and  watch  them  come  and  go.  He 
thought  these  two  monstrosities  the  property  of  the  government 
and  that  they  were  intended  for  the  amusement  of  the  patient. 

Another  patient  saw  flocks  of  partridges  about  his  room  and  a 
turkey  an  inch  high  on  his  window  sill.  Spiders  and  thousand- 
legged  bugs  came  crawling  on  his  bed.     These  hallucinations  pro- 


222  OUTLINES   OF   PSYCHIATRY. 

duced'  no  surprise  or  disgust.  He  merely  cited  them  as  of  passing 
interest  while  talking.  His  aunt's  face  was  lying  next  to  him  on 
the  bed  and  he  tried  to  kiss  it.  Another  patient  in  the  hospital 
saw  about  him  numerous  men  of  Lilliputian  dimensions  and  dis- 
played the  liveliest  interest  in  these  strange  little  people. 

Often  dreamy  hallucinations  and  delusions  relate  altogether  to 
his  occupation  and  the  patient  busies  himself  with  his  usual  pur- 
suits— occupation  delirium.  Physically  he  is  in  a  condition  of 
acute  exhaustion.  The  pulse  is  rapid  and  of  low  tension,  the 
temperature  normal  or  only  slightly  elevated  (occasionally  high, 
the  febrile  delirium  tremens  of  Magnan),  the  body  bathed  in  a 
profuse  perspiration  and  constantly  agitated  by  muscular  shocks 
and  tremors.  Occasionally  one  sees  cases  ushered  in  by  all  the 
typical  prodromal  symptoms,  sweating,  atonic  dyspepsia,  restless- 
ness, tremor,  precordial  distress,  anxiety  and  disturbed  sleep, 
which  do  not  proceed  to  the  typical  condition  of  mental  confusion 
with  multiform  hallucinations.  This  is  the  so-called  abortive 
type,  the  delirium  sine  delirio  of  Dollken. 

During  the  course  of  the  disease  almost  any  experience  the 
patient  may  have,  any  impression  made  upon  his  sensorium  is 
woven  into  the  warp  and  woof  of  his  delirious  experiences — 
sensory  flight  of  ideas.  Hallucinations  seem  to  arise  sponta- 
neously or  are  easily  produced  by  pressure  on  the  eyeball  or  merely 
by  getting  the  patient  to  look  at  a  blank  piece  of  paper.  Para- 
phasia and  paralexia  are  commonly  present. 

Albuminuria  is  found  in  a  considerable  proportion  of  cases, 
probably  considerably  over  50  per  cent.,  during  the  early  stages. 
At  the  height  of  the  delirium  leucocytosis  has  been  found.  It 
must  not  be  forgotten,  too,  that  here,  as  in  acute  toxic  states  gen- 
erally, a  sluggish  reaction  of  the  pupil  to  light  and  even  complete 
Argyll-Robertson  pupil  may  be  found.  This  sign  disappears,  how- 
ever, on  recovery.  This  is  an  important  fact  to  be  borne  in  mind 
in  the  matter  of  diagnosis.  Whether  it  means  the  presence  of 
syphilis,  as  some  suppose,  can  be  determined  by  blood  tests. 

Acute  cardiac  dilatation  may  develop  at  the  height  of  the 
disease. 

Course  and  Duration. — The  psychosis  runs  an  acute  course  of 
about  three  days  and  terminates  in  recovery  in  the  majority  of 
cases.  The  delirium  usually  ends  in  a  long  sleep.  About  10  to 
15  per  cent.  die. 


THE  TOXIC  PSYCHOSES.  223 

Pathology. — Degenerative  conditions  are  found  in  the  central 
nervous  system — acute  degenerations  of  the  ganglion  cells,  and 
recent  hemorrhages.  The  ganglion  cells  are  found  shrunken  and 
there  is  increase  in  the  glia  and  some  vascular  proliferation  with 
slight  round-celled  infiltration.  There  may  be  a  chronic  lepto- 
meningitis and  some  narrowing  of  the  cell  layers  of  the  convolu- 
toins.  Changes  are  also  found  in  the  cerebellum.  The  altera- 
tions in  the  Purkinje  cells  are  supposed  to  be  correlated  with  the 
motor  symptoms — tremor  and  ataxia  (Kraepelin,  Allers). 

Wassermeyer  is  of  the  opinion  that  the  pathology  indicates 
that  the  delirium  results  from  an  increase  in  the  chronic  alcohol 
poisoning  rather  than  a  metabolism  poison. 

Chronic  Alcoholism. — The  effects  of  chronic  alcohol  poison- 
ing are  exhibited  in  every  organ  of  the  body,  niore  particularly 
the  central  nervous  organs,  stomach,  pancreas,  liver,  kidneys  and 
blood  vessels,  and  give  rise  to  characteristic  symptoms  as  a  result, 
the  most  prominent  of  which  are  tremor,  gastric  catarrh,  arterio- 
sclerosis, albuminuria  and  progressive  mental  enfeeblement. 

The  effects  on  the  nervous  system  are  shown  in  disturbances 
of  sensation,  motion  and  the  intellect.  The  sensory  disturbances 
are  paresthesia  (prickling,  tingling,  formication),  hyperesthesia 
and  hyperalgesia  and  anesthesia.  The  sensory  disorders  of  the 
special  senses  involve  principally  the  eye  and  ear,  producing  illu- 
sions and  hallucinations,  muscae  volitantes,  photopsia,  amblyopia 
and  amaurosis,  diminution  of  the  acuteness  of  hearing  with  the 
production  of  subjective  noises  (hissing,  ringing,  roaring,  etc.), 
due  to  middle  or  internal  ear  disease. 

The  motor  disturbances  are  tremor,  spasms  and  cramps,  epilep- 
tiform attacks,  general  motor  enfeeblement  with  paresis. 

The  mental  changes  are  gradual  and  progressive,  the  intellect 
is  obtunded,  the  judgment  overthrown,  the  moral  sense  blunted, 
and  mendacity  appears  in  its  most  bizarre  forms ;  delusions  may 
develop,  the  most  characteristic  of  which  is  marital  infidelity  and 
jealousy,  and  the  patient  sinks  gradually  into  a  condition  of  per- 
manent mental  enfeeblement. 

Diagnosis. — Alcoholic  dementia  is  to  be  differentiated  from 
other  dementias  largely  by  the  history.  Alcoholic  dementia  will 
have  a  history  of  progressive  mental  enfeeblement  closely  asso- 
ciated with  alcoholic  indulgence. 


224  OUTLINES   OF   PSYCHIATRY. 

Graeter^  has  recently  called  particular  attention  to  the  asso- 
ciation of  alcoholism  and  dementia  precox.  Many  of  the  cases  of 
mental  deterioration  associated  with  over-indulgence  in  alcohol 
will  be  found  to  be  true  cases  of  precox  in  which  the  alcohol  is 
only  an  incidental  and  associated  feature. 

Alcoholic  Pseuido-Paresis. — On  a  groundwork  of  mental  en- 
feeblement  the  alcoholic  may  develop  a  true  expansive  delirium 
which,  combined  with  the  signs  of  alcoholism  (ataxia,  speech 
defects,  tremor,  pupillary  anomalies  and  muscular  weakness), 
may  make  the  distinction  from  paresis  difficult — alcoholic  pseudo- 
paresis.  This  similarity  to  paresis  is  noticeable  even  when  the 
expansive  delirium  is  absent  in  cases  in  which  the  mental  reduc- 
tion is  marked,  but  becomes  greatest  when  the  symptom  complex 
above  outlined  is  ushered  in  by  epileptiform  attacks. 

Diagnosis. — The  distinction  from  true  paresis  can  usually  be 
made.  Pupillary  inequality  is  more  common  and  the  permanent 
results  of  apoplectic  insults  (hemiplegia,  aphasia)  more  often 
found  in  the  alcoholic  form  than  in  the  true.  The  results  of 
polyneuritis  should  be  looked  for  and  if  found  suggest  alcoholism. 
The  most  reliable  differential  sign  is  found  in  the  course  of  the 
two  maladies.  True  paresis  is  progressive,  tending  toward  ever- 
increasing  degradation,  while  in  the  alcoholic  form  removal  of 
the  poison  results  very  shortly  in  a  remission  of  all  the  symptoms, 
even,  in  some  cases,  amounting  to  a  recovery.  The  symptoms, 
however,  reappear  subsequently  if  drinking  habits  are  returned  to. 

It  must  not  be  forgotten  that  an  Arg}41-Robertson  pupil  may 
be  transiently  present.  When  there  is  a  question  whether  both 
this  sign  and  the  whole  pseudo-paretic  picture  may  not  be  de- 
pendent upon  the  presence  of  sj-philis  blood  tests  should  be  made. 

Alcoholic  Epilepsy. — As  a  result  of  chronic  alcoholic  toxemia, 
the  symptoms  of  which  are  marked  throughout  by  their  explosive 
character,  it  is  not  strange  that  actual  convulsions,  alcoholic 
epilepsy,  should  complicate  the  morbid  picture.  These  convul- 
sions, so  far  as  their  individual  characteristics  are  concerned,  are 
indistinguishable  from  true  epilepsy.  Occurring,  however,  in  a 
person  beyond  the  period  of  adolescence  who  is  addicted  to  the 
immoderate  use  of  alcohol,  their  origin  should  be  suspected.  The 
diagnosis  is  made  clear  if  they  cease  upon  the  withdrawal  of 

**  Graeter :  Dementia  Praecox  mit  Alcoholismus  Chronicus,  Leipzig,  ipog. 


THE   TOXIC   PSYCHOSES.  22  5 

alcohol.  As  this  sometimes  does  not  occur  the  diagnosis  can  be 
made  only  by  excluding  the  causes  both  of  true  and  symptomatic 
epilepsy  other  than  from  alcohol. 

Alcoholic  Hallucinosis. — This  psychosis  may  come  on  sud- 
denly in  a  chronic  alcoholic,  following  an  unusual  excess,  or  it 
may  be  of  gradual  evolution.  It  is  sometimes  preceded  by  one 
or  more  attacks  of  delirium  tremens.  It  is  characterized  by 
hallucinations,  auditory  predominating,  thus  contrasting  strongly 
with  the  predominance  of  the  visual  hallucinations  in  delirium 
tremens. 

The  delusions  are  of  a  persecutory  nature,  in  which  the  sexual 
element  is  frequently  prominent  and  show  a  tendency  to  systema- 
tization.  The  system,  however,  is  of  rapid  growth  and  loosely 
organized. 

Schneider^  as  a  result  of  a  study  of  a  series  of  cases  does  not 
believe  that  this  psychosis  is  sufficeintly  explained  by  alcohol. 
He  draws  attention  to  the  facts  that  attacks  of  hallucinosis  occur 
altogether  aside  from  alcoholic  indulgence;  that  other  sorts  of 
psychoses  may  result  from  alcohol ;  and  that  many  drink  to  excess 
without  developing  a  psychosis  at  all.  He  also  notes  that  patients 
may  have  had  many  previous  debauches  without  a  psychosis.  He 
therefore  believes  that  the  make-up  is  an  important  element,  but 
that  the  psychosis  only  occurs  as  a  result  of  a  psychogenic  pre- 
cipitating factor  in  addition  to  alcohol  and  that  the  content  of  the 
hallucinations  is  determined  by  this  factor.  Some  of  the  instances 
given  in  the  following  illustrations  indicate  this. 

Whether  of  sudden  or  gradual  onset,  the  first  symptoms  are 
hallucinations,  with  which  persecutory  delusions  are  intimately 
bound  up.  The  patient  hears  voices  making  all  sorts  of  inimical 
remarks,  telling  him  that  his  children  are  not  his  own,  calling 
him  an  onanist,  reviling  or  threatening  him.  In  every  way  his 
persecutors  annoy  him  by  their  malign  comments.  Visual  hallu- 
cinations are  rare.  Hallucinations  of  smell  and  taste  are  not 
infrequent.  The  auditory  hallucinations,  quite  characteristically, 
tend  to  fall  into  rhythm  with  outside  sounds,  as,  for  example,  in 
one  of  my  cases,'^  the  humming  of  a  dynamo. 

6  Schneider,  Carl  von  A. :  Studies  on  Alcoholic  Hallucinoses,  Psychi- 
atric Bulletin,  Jan.,  1916. 

T  White:  A  Case  of  Unilateral  Hallucinosis  (Alcoholic),  Bulletin  No.  i, 
Govt.  Hosp.  for  the  Insane. 


226  OUTLINES   OF  PSYCHIATRY. 

The  delusions  of  this  state  harmonize  well  with  the  hallucina- 
tions. The  patient  is  persecuted  by  invisible  enemies  who  inject 
noxious  vapors  in  his  room  at  night,  poison  his  food,  draw  oflf 
his  semen,  and  produce  nocturnal  pollutions. 

One  patient  heard  voices  of  enemies  whispering  at  the 
windows;  they  were  going  to  kill  him,  called  him  a  variety  of 
unpleasant  names  and  accused  him  of  all  sorts  of  crimes.  The 
patient  attempted  suicide.  He  gives  a  history  of  being  troubled 
with  noises  in  his  ear  for  a  considerable  time,  resembling  the 
click  of  a  telegraph  machine.  When  he  is  drinking  these  noises 
become  voices.  Another  patient  thought  he  heard  different  peo- 
ple talking  about  him,  cursing  him,  and  calling  him  vile  names. 
Then  later  he  thought  he  heard  his  thoughts  repeated.  While  on 
his  drinking  bout  he  wandered  about  aimlessly,  felt  that  he  was 
being  pursued  and  heard  threats  made  against  him.  Bought  a 
knife  and  walked  into  the  water.  In  the  hospital  he  heard  his 
old  friends  accusing  him  of  sexual  perversions,  pederasty,  etc. 
Tells  of  having  heard  his  associates  say,  "  He  is  no  good ;  we  will 
get  him  out  of  the  army,"  and  "  He  is  a  sucker  for  fixing  a  horse 
instead  of  allowing  the  veterinary  to  do  it,"  etc.  Another  pa- 
tient, a  sailor,  had  been  drinking  heavily  while  on  shore.  When 
three  days  out  at  sea  he  began  to  hear  threats  against  him.  He 
heard  the  men  say  that  they  would  kill  him,  they  would  cut  his 
heart  out,  and  cut  him  into  fifty  thousand  pieces.  On  the  evening 
of  the  third  day  he  could  stand  it  no  longer  and  thinking  that  he 
saw  land  ahead  he  jumped  overboard. 

Grandiose  delusions  do,  however,  occasionally  occur,  though 
they  are  not  sufficiently  controlling  to  modify  the  picture  in  any 
essential  way.  A  case  cited  by  Mitchell^  shows  how  they 
usually  manifets  themselves.  In  this  case,  in  the  midst  of  an 
active  hallucinosis,  during  which  the  patient  was  constantly  hear- 
ing voices  coming  from  the  air,  and  out  of  the  floor,  and  the 
passing  trains  were  whistling  his  name,  and  while  he  saw  faces 
staring  at  him  from  the  walls,  he  had  an  episode  during  which  he 
assumed  charge  of  affairs,  gave  orders,  and  threatened  with  death 

*>  Mitchell :  Types  of  Alcoholic  Insanity,  with  Analysis  of  Cases,  Am. 
Jour,  of  Insanity,  Oct.,  1904. 


THE  TOXIC   PSYCHOSES.  22/ 

the  doctors  who  refused  to  obey.  Bonhoeffer®  only  gives  one 
case  with  grandiose  ideas,  which,  however,  were  only  of  tem- 
porary duraition  during  the  course  of  an  hallucinosis  with  audi- 
tory hallucinations  of  a  distinctly  threatening  character,  and  one 
case  in  which  the  patient  heard  music,  but  otherwise  had  disa- 
greeable hallucinations. 

In  this  state  the  patient  is  depressed,  apprehensive,  often  fear- 
ful of  impending  danger,  may  have  anxious  and  angry  states,  and 
often  reacts  by  attacking  his  supposed  persecutors.  Throughout 
this  condition  the  patient  is  well  oriented  and  consciousness  is 
clear. 

Some  of  these  cases  run  a  long  course  and  become  chronic. 

Diagnosis. — The  diagnosis  from  delirium  tremens  is  made  by 
the  absence  of  disorientation  and  by  the  marked  prevalence  of 
auditory  hallucinations  in  the  form  of  threatening  voices.  It 
must  not  be  forgotten  that  there  exist  cases  that  are  intermediate 
in  their  symptomatology  between  delirium  tremens  and  acute 
hallucinosis.  From  paranoia  the  distinction  is  made  by  the  very 
rapid  systematization  of  the  delusional  system,  as  opposed  to  the 
slow  evolution  in  that  disease. 

Alcoholic  Pseudo-Paranoia. — In  some  cases  of  chronic  alco- 
holism a  paranoid  state  is  developed,  in  which  psycho-sensory 
disturbances  (hallucinations)  may  be  of  secondary  importance  or 
not  present  at  all.  The  characteristic  delusion  in  these  cases  is 
that  of  marital  infidelity. 

While  some  of  these  cases  develop  primarily  upon  a  background 
of  chronic  alcoholism,  others  may  follow  directly  upon  an  attack 
of  hallucinosis  or  delirium  tremens. 

These  cases  have  a  long  course,  poor  prognosis  and  may  termi- 
nate in  consideraible  impairment. 

Diagnosis. — This  delusion  of  marital  infidelity  and  jealousy 
may  not  be  accompanied  by  any  noticeable  degree  of  impairment 
of  judgment  or  mental  enfeeblement,  and  in  these  cases  it  may 
be  extremely  difficult  to  make  a  differential  diagnosis  between  this 
form  of  alcoholic  psychosis  and  true  paranoia.  Particularly  is  it 
difficult  to  recognize  paranoia  with  subsequent  or  coincident  alco- 
holic indulgence. 

»  Bonhoeflfer,  K. :  Die  akuten  Geisteskrankheiten  der  Gewohnheitstrinker. 
Verlag  von  Gustav  Fischer  in  Jena,  1901. 


228  OUTLINES   OF   PSYCHIATRY. 

Certain  other  paranoid  conditions,  especially  of  the  involution 
period,  may  present  this  picture  with  the  characteristic  delusions 
of  jealousy. 

Differentiation  is  made  by  excluding  alcohol  in  the  anamnesis. 

Korsakow's  Psychosis. — The  mental  state  of  this  psychosis 
accompanies  polyneuritis  and  is  usually  of  alcoholic  origin,  but 
may  be  caused  by  other  poisons,  as  those  of  typhus,  tuberculosis, 
influenza,  diabetes,  the  metallic  poisons,  etc.,  and  the  Korsakow 
syndrome  is  seen  not  infrequently  in  general  paresis  and  in  senil- 
ity.    The  signs  of  polyneuritis  may  be  very  slight. 

Symptoms. — The  patient  is  a  chronic  alcoholic  and  may  enter 
the  hospital  suffering  from  delirium  tremens.  The  delirium  in- 
stead of  clearing  completely,  as  is  usual,  merges  into  Korsakow's 
psychosis  which  has  often  been  called  chronic  alcoholic  delirium 
in  contradistinction  from  delirium  tremens  which  is  an  acute  alco- 
holic delirium. 

The  mental  symptoms  are  the  result  of  a  characteristic  com- 
bination of  attention  and  memory  disorder.  The  result  is  a  pecu- 
liar type  of  amnesia.  There  is  a  defect  in  the  recording  of  present 
events  resulting  in  an  anterograde  amnesia.  In  more  severe  cases 
this  amnesia  may  reach  back  a  considerable  distance — retrograde 
amnesia — but  the  events  of  early  life  and  long  distant  occurrences 
are  well  remembered. 

This  defect  of  memory  is  associated  with  a  composed  bearing 
and  apparent  lucidity  on  casual  questioning.  A  more  careful  ex- 
amination, however,  will  show  not  only  this  memory  defect,  but 
probably  also  that  the  patient  is  disoriented  as  to  time  and  place. 

The  characteristic  symptom  is  associated  with  the  amnesia  and 
consists  of  a  peculiar  falsification  of  memory.  The  gaps  in 
memory  are  filled  by  all  sorts  of  fabrications  which  are  narrated 
in  great  detail  and  with  a  perfect  appearance  of  lucidity — oppor- 
tune confabulation. 

A  patient  who  has  been  confined  to  his  bed  for  days  with  foot- 
and  wrist-drop  tells  me,  when  asked  where  he  was  the  day  before, 
about  having  gone  to  the  races  and  details  his  conversation  with 
different  persons,  describes  the  events,  tells  what  horses  won  and 
the  like. 

One  such  patient  says  to  the  physician  on  approaching  the  bed : 
"I  am  pretty  sleepy.     I  have  just  had  a  nap  over  home  and  I 


THE  TOXIC   PSYCHOSES.  229 

came  over  here  to  lie  down  again."  Asked  if  his  wife  had  been 
to  see  him  lately  (she  had  called  the  day  before),  said  that  he 
saw  her  two  days  ago  and  added:  "I  was  just  out  there  at  the 
front  window  a  few  moments  ago  to  see  if  she  was  coming." 
Being  questioned  as  to  what  he  had  for  dinner  yesterday  (he  was 
on  a  milk  diet),  said  he  had  "  Some  delicious  New  York  plums, 
the  usual  vegetables,  and  cocoa." 

Often  delirious  experiences  seem  to  be  related  to  the  neuritic 
pain.  This  same  patient  told  once  how  a  big,  black,  burly,  ugly 
negro  grabbed  his  sore  legs  two  days  before  and  how  it  made  him 
angry. 

Another  patient  tells  how  two  years  ago  he  was  chloroformed 
by  unknown  parties.  He  awoke  just  as  they  had  escaped  from 
the  room  and  saw  a  machine  on  his  right  foot.  (He  suffers  from 
pain  and  weakness  in  this  foot  and  ankle.)  This  was  crushing 
the  tendons  of  the  instep.  He  immediately  dropped  off  to  sleep 
again.  When  he  awoke  the  next  morning  the  instrument  of  tor- 
ture had  been  removed,  but  he  suffered  from  pain  and  weakness 
in  that  right  foot  and  also  to  some  extent  in  the  left  foot 

In  many  cases  the  fabrications  can  be  suggested  by  leading 
questions  and  the  patient  may  be  led  to  make  almost  any  state- 
ments, no  matter  how  contradictory — suggestion  confabulation. 

One  patient,  confined  to  bed,  asked  what  he  did  the  day  before, 
replied :  "  I  took  the  horse  and  buggy  out  and  took  a  drive,  my 
father  being  in  Baltimore;,  I  don't  know  whereabouts  I  had  him 
fed ;  I  went  down  Pennsylvania  Ave.  and  Fourteenth  Street." 

Another  patient,  when  asked  what  she  had  for  breakfast,  pro- 
ceeded to  give  a  bill  of  fare,  none  of  the  articles  of  which  she 
really  had  had. 

These  pseudo-reminiscences  are  usually  unstable  and  fleeting, 
or  at  least  seldom  told  twice  alike.  Such  for  instance  is  the 
following:  "A  few  weeks  ago  I  was  out  walking  on  the  Wash- 
ington Heights,  you  know,  just  beyond  the  Treasury,  with  a 
friend.  It  was  during  lunch  hour  at  the  office.  We  saw  some 
cattle  grazing  on  the  hillside  and  we  thought  we  would  have  a 
little  shooting  match.  I  went  down  to  the  man  and  he  gave  me 
a  gun  and  I  fired  away  and  hit  a  steer  right  behind  the  ear.  It, 
of  course,  killed  him.  They  all  laughed  and  considered  me  a 
crack  shot.     They  sent  me  a  check  for  it  the  next  day.     It  was 


230  OUTLINES   OF   PSYCHIATRY. 

for  a  pretty  large  amount  but  I  do  not  remember  just  how  much. 
I  suppose  by  looking  up  the  records  I  could  find  just  how  much 
they  did  give  me." 

Sometimes,  however,  some  of  them  become  fixed.  It  is  fairly 
common,  for  example,  for  women  to  believe  and  act  as  though 
they  had  a  baby  in  bed  with  them. 

With  this  state  of  mind  the  patient  is  usually  very  poorly 
oriented  if  not  completely  disoriented.  His  time  sense  is  par- 
ticularly aflfected. 

Physically  the  patient  typically  has  all  the  signs  of  a  polyneu- 
ritis which  of  course  dififers  in  its  distribution  according  to  the 
etiological  factor.  In  the  alcoholic  type,  which  is  the  most  com- 
mon, wrist-  and  foot-drop  are  characteristic  symptoms.  Of 
course  various  unusual  and  anomalous  involvements  may  occur, 
for  example,  of  the  cranial  nerves.  Bulbar  and  vagus  involve- 
ment are  naturally  most  serious. 

Inasmuch  as  the  pathology  of  the  disease  shows  that  it  is  not 
confined  to  the  peripheral  nerves,  but  is  general,  involving  the 
whole  of  the  nervous  system,  cord,  basal  ganglia,  and  cortex  and 
inasmuch  also  as  there  seems  to  be  some  tendency  to  the  focali- 
zation  of  the  pathologic  process,  we  might  expect  to  find,  and  as 
a  matter  of  fact  do  find  in  certain  cases,  focal  symptoms.  These 
are  the  various  types  of  aphasia,  apraxia,  reading  and  writing 
disturbances,  homonymous  hemianopia,  etc. 

When  the  focalization  of  the  pathological  changes  takes  place 
in  the  mid-brain  it  produces  the  syndrome  of  acute  hemorrhagic 
polioencephalitis  of  Wernicke,  a  very  serious  involvement, 
typically  ushered  in  by  severe  vomiting,  followed  by  delirium, 
vertigo,  and  sometimes  headache  and  somnolence,  various  ocular 
palsies,  and  perhaps  complicated  by  optic  neuritis.  Death  usually 
issues  in  from  one  to  two  weeks. 

Pupillary  disturbances  are  not  infrequent.  Inequality  of  the 
pupils,  sluggishness  to  light  and  accommodation  reflexes,  and 
transitory  Argyll-Robertson  pupil  may  be  present.  More  rarely 
various  kinds  of  ocular  palsies  or  muscular  weaknesses  occur. 

Clinical  Forms. — Various  clinical  types  of  the  disease  have 
been  described  according  to  the  prominence  of  special  symptoms. 
Thus  DuPRE^^  describes  five  as  follows:  (i)  Amnesic,  (2)  con- 

^"  Cited  by  Jelliflfe :  The  Alcoholic  Psychoses.  Chronic  Alcoholic  De- 
h'rium  (Korsakoff's  Psychosis),  New  York  Med.  Jour.,  Oct.  24,  1908. 


THE  TOXIC   PSYCHOSES.  23 1 

fusional,  (3)  delusional,  (4)  anxious,  and  (5)  demented 
Knapp^^  describes  eleven  forms:  (i)  Delirious,  (2)  stuporous, 
(3)  demented,  (4)  hallucinatory  without  systematization  of  false 
ideas,  (5)  hallucinatory  with  systematization  of  false  ideas,  (6) 
paranoid,  (7)  anxious,;  (8)  expansive,  (9)  manic  and  melan- 
cholic, (10)  poylneuritic  motility  psychosis  (of  Wernicke),  and 
(11)  anomalous.  Of  course  it  will  be  understood  that  this  sepa- 
ration of  forms  of  the  disease  is  nothing  more  than  giving  the 
name  of  the  most  prominent  symptom.  Thus  in  the  stuporous 
type  stupor  is  especially  in  evidence,  etc. 

Diagnosis. — The  associatiaon  of  the  peculiar  falsification  of 
memory  with  confabulation  and  usually  disorientation  with  foot- 
and  wrist-drop  is  characteristic.  Paresis  is  to  be  distinguished  by 
the  absence  of  evidences  of  polyneuritis. 

Dream  States. — Less  common  and  more  unusual  effects  of 
alcohol  are  the  conditions  of  so-called  trance,  automatism,  double 
consciousness,  spontaneous  somnambulism,  which  are  followed  by 
amnesia.  In  these  conditions  the  subject  of  alcoholism  may  do 
almost  anything  imaginable,  make  contracts,  transfer  property, 
commit  criminal  acts,  take  long  journeys,  enter  into  complicated 
business  or  professional  transactions,  and  later  have  absolutely  no 
knowledge  of  what  he  has  done.  During  a  protracted  debauch 
the  subject  may  suddenly  start  off  on  a  journey  and  travel  under 
an  assumed  name,  meanwhile  conducting  himself  in  such  a  man- 
ner as  not  to  lead  to  any  comment  on  the  part  of  those  whom  he 
meets.  Suddenly,  without  warning  or  after  a  night's  sleep,  he 
"  wakes  up  "  to  a  realization  of  his  true  situation  with  absolutely 
no  memory  of  how  he  got  where  he  is  or  what  he  has  been  doing 
since  he  started  away  from  home.  As  the  name  indicates,  this 
condition  has  been  described  as  one  of  automatism,  but  a  moment's 
consideration  will  serve  to  show  that  acts  of  such  a  complex 
character  cannot  be  automatic  acts.  The  fact  that  no  recollection 
remains  of  what  was  done  has  been  used  to  argue  unconscious- 
ness, but  that  is  equally  inconceivable.  Hundreds  of  miles  could 
not  be  travelled  by  an  unconscious  man  without  attracting  atten- 
tion. The  mere  fact  that  the  patient  has  forgotten  what  occurred 
is  no  reason  why  he  must  necessarily  have  been  unconscious.  I 
have  been  fully  able  to  demonstrate  that  consciousness  actually 

11  Knapp :  cited  by  Jelliffe,  loc.  cit. 


232  OUTLINES   OF   PSYCHIATRY, 

did  exist  in  certain  cases  that  I  have  studied  which  were  followed 
by  amnesia,  and  as  a  result  I  am  convinced  that  the  same  condi- 
tion might  be  found  to  exist  in  others.  Some  persons  are  espe- 
cially lia:ble  to  this  form  of  mental  disturbance,  and  it  may  repeat 
itself  on  the  occasion  of  renewed  intoxication.  Its  psychopatho- 
logical  basis  is  probably  a  dissociation  of  consciousness. 

Dipsomania. — A  periodical  impulse  to  drink — is  an  expression 
of  deep-seated  neuropathic  taint. 

Course. — ^Chronic  alcoholism,  whether  interrupted  or  not  by 
any  of  the  forms  of  mental  disturbance  described  in  this  chapter, 
tends  to  an  ever-increasing  dementia,  alcoholic  dementia.  Mental 
enfeeblement  is  a  symptom  from  the  outset  and  is  noticeable  at 
first  in  the  esthetic  and  moral  sphere.  The  previously  proud, 
well-dressed  man  becomes  slovenly  in  his  habits  and  unkempt  in 
his  appearance.  Incapable  of  the  close  and  continuous  mental 
application  of  former  years  it  becomes  impossible  for  him  to  meet 
the  requirements  of  his  business  or  professional  life  and  lying  is 
resorted  to  in  finding  excuses.  This  is  followed  by  moral  obliqui- 
ties of  a  more  serious  nature  in  which  the  sexual  element  is  apt  to 
predominate  and  result  in  medico-legal  complications.  Memory 
is  early  and  noticeably  affected.  The  everyday  affairs  of  life  are 
forgotten,  so  that  the  subject  of  alcoholism  neglects  to  keep  ap- 
pointments, forgets  important  business  engagements,  etc.  Judg- 
ment and  the  reasoning  faculties  are  similarly  enfeebled,  until 
finally  the  most  profound  degree  of  dementia  is  reached,  hastened 
perhaps  by  apoplectic  insults  which  are  not  uncommon. 

Pathology. — The  gross  pathology  of  alcoholism  has  already 
been  indicated.  Cirrhotic  liver,  chronic  nephritis,  fatty  heart, 
chronic  gastritis,  arteriocapillary  fibrosis,  cerebral  arteriosclerosis 
and  cerebral  hemorrhage. 

The  principal  lesions  found  in  the  brain  are  pachymeningitis, 
edema,  congestion,  thickening  and  opacity  of  the  piarachnoid, 
atrophy  of  the  convolutions,  sclerosis  of  the  vessels,  degeneration 
of  the  cells  and  increase  of  neuroglia. 

Treatment. — The  treatment  of  delirium  tremens  and  the  other 
acute  alcoholic  psychoses  should  be  supporting;  liquid  concen- 
trated food  predigested  if  necessary.  The  bowels  should  be  kept 
free  and  the  kidneys  kept  flushed  by  a  goodly  supply  of  fluid. 
Heart  stimulants  are  often  necessary,  digitailis,  caffeine,  strych- 


THE  TOXIC   PSYCHOSES.  233 

nine,  to  combat  cardiac  failure,  and  hypnotics  to  induce  sleep  and 
give  rest.  The  latter  should  be  carefully  selected  with  reference 
to  the  patient's  condition,  depressing  agents,  such  as  chloral,  giving 
place  to  safer  ones  as  trional  if  there  is  much  heart  embarrass- 
ment. The  after-treatment  consists  of  abstinence  from  alcohol, 
tonics,  nourishing  food  and  regulation  of  the  emunctories. 

For  the  excitement  especially  hydrotherapy  in  the  form  of  the 
continuous  bath  is  valuable.  The  thing  to  be  kept  constantly 
in  mind  in  these  cases  is  the  matter  of  nourishment.  If  the  pa- 
tient does  not  take  sufficient  food  tube  feeding  should  be  begun 
at  once  without  any  delay  in  temporizing.  Food  alone  will  often 
ameliorate  in  a  remarkable  manner  the  excitement  and  the 
insomnia. 

The  medical  treatment  of  chronic  alcoholism  should  be  tonic 
and  supporting.  Strychnine  for  a  general  nervous  and  cardiac 
stimulant,  ergot  if  there  be  symptoms  of  "  wet  brain,"  capsicum 
and  bitter  tonics  for  the  gastric  condition  of  anorexia;  attention 
to  the  emunctories,  moderate  exercise,  baths,  massage  and  elec- 
tricity for  their  general  tonic  effects;  sedatives  and  hypnotics 
with  caution ;  a  modified  "  rest  treatment "  if  there  is  marked 
neurasthenia,  and  later  a  sufficient  amount  of  mental  and  bodily 
exercise  to  keep  the  patient  healthfully  occupied.  Lambert  has 
had  marked  success  with  Livingston^^  solution. 

The  matter  of  isolation  is  an  important  one.  I  feel  convinced 
that  in  all  cases  in  which  the  habit  is  firmly  fixed  isolation  is 
highly  desirable,  if  not  imperative,  as  in  these  cases  the  patient  is 
unable  to  resist  temptation  and,  as  soon  as  opportunity  presents 
itself,  will  lapse.  After  confinement  for  a  few  months,  during 
which  the  patient  is  restored  as  far  as  possible  to  physical  health, 
he  is  in  condition  to  abstain  if  he  wants  to  and  is  able;  if  he  does 
not  wish  to  or  if  he  suffers  from  too  great  weakness  of  will,  he 
will  return  to  his  old  practices  and  his  case  is  hopeless.  If  he 
does  wish  to  stop  drinking,  however,  he  has  been  given  the  best 
possible  opportunity,  an  opportunity  which  should  be  early  ex- 
tended in  all  cases  and  not  offered  when  by  long-continued  indul- 

^2  Livingston's  solution  is  one  drachm  solid  extract  ergot  dissolved  in  an 
ounce  of  sterile  water  -|-  three  drops  chloroform  and  three  grains  chlore- 
tone  and  filtered.     Give  thirty  drops  hypodermically  every  two  to   four 
hours  into  muscles  of  gluteal  region  or  deltoid — never  subcutaneously. 
16 


234  OUTLINES   OF  PSYCHIATRY. 

gence  the  case  is  of  necessity  hopeless.  A  psychoanalytic  ap- 
proach to  the  patient's  problems  is  of  course  indicated  and  could 
be  carried  out  to  the  best  advantage  during  the  period  of  isolation. 

Opium. 

Cause. — As  in  other  varieties  of  narcomania  the  most  impor- 
tant cause  is  the  neuropathic  diathesis.  In  this  class  of  patients 
the  habit  is  often  initiated  by  the  use  of  morphine  to  relieve  the 
periodic  pains  of  neuralgia,  tabes,  dysmenorrhea,  rheumatism,  etc., 
or  the  mental  depression  incident  to  worry,  loss  of  position,  grief 
and  the  like,  A  great  many  cases  are  unfortunately  traced  to  the 
carelessness  of  physicians  in  prescribing  the  drug,  and  as  if  in 
retribution  medical  men  furnish  the  largest  quota  of  sufferers 
(fifteen  per  cent). 

Symptoms  and  Diagnosis. — The  symptoms  of  a  single  dose 
are  at  first  those  of  mild  stimulation  of  the  mental  faculties  fol- 
lowed by  a  period  of  quiet,  half-waking,  half-sleeping,  interrupted 
by  multiform  pleasant  hallucinations  (predominantly  visual) 
which  show  no  tendency  to  delusive  elaboration  in  the  waking 
state.  This  condition  is  followed  by  malaise,  headache,  dry 
mouth,  constipation  and  nausea. 

The  physical  symptoms  of  prolonged  use  of  opium  in  any  of 
its  forms  are  anorexia,  irregular  action  of  bowels,  constipation 
alternating  with  diarrhea,  cardiac  weakness,  general  muscular 
weakness  and  tremor,  miosis  and  sluggish  pupils,  impotence, 
amenorrhea,  diminished  sensibility,  paresthesias,  sensation  of 
coldness. 

Mentally  there  is  a  gradual  degradation.  The  memory  and 
power  of  attention  become  impaired  and  the  capacity  for  initia- 
tion is  lost.  There  is  marked  impairment  in  the  ethical  feelings 
and  previously  honest  persons  will  begin  by  lying  out  of  business 
engagements  and  about  the  taking  of  the  drug  and  end  by  asso- 
ciating with  the  most  degraded  persons  and  resorting  to  any 
means  whatever,  even  criminal,  to  obtain  the  drug. 

Some  persons  who  have  taken  opium  in  some  form  for  a  con- 
siderable time  and  in  large  doses  develop  an  hallucinated  state 
that  may  be  of  paranoid  coloring  or  may  be  distinctly  delirioid. 
Thus  one  patient  (laudanum  and  whiskey)  on  admission  to  the 
hospital  said  that  her  food  was  poisoned.     Another  patient  (mor- 


THE  TOXIC   PSYCHOSES.  235 

phine)  is  restless  and  excited,  has  hallucinations  of  hearing  and 
carries  on  conversation  with  imaginary  persons.  Sometimes  her 
language  is  violent  and  abusive,  she  threatens  her  imaginary  per- 
secutors and  will  jump  out  of  bed  and  run  through  the  hallway 
looking  for  the  people  she  thinks  are  after  her. 

The  diagnosis  can  often  not  be  made  without  the  anamnestic 
data.  The  patients  frequently  deny  their  habit — mendacity  is  a 
prominent  symptom,  and  they  are  often  cute  enough  to  find  means 
of  indulgence  even  though  carefully  watched.  The  moral  degra- 
dation is  pronounced  and  they  will  go  any  length  to  obtain  their 
drug.  Symptoms  which  should  excite  suspicion  are  periods  of 
torpor  and  languor  in  marked  contrast  to  the  activity  of  alcohol- 
ism, amounting  at  times  to  an  inability  to  even  sit  up,  occasional 
signs  of  stimulation,  temall  pin-point  pupils,  yeUowish-brown 
cachectic  complexion,  and,  above  all,  the  numerous  scars  of  hypo- 
dermic injections.  In  conditions  in  which  a  diagnosis  is  neces^ 
sary  it  is  to  be  remembered  that  morphine  can  be  recovered  from 
the  urin€  and  stomach. 

The  least  serious  method  of  taking  the  drug  is  by  smoking,  the 
next  more  serious  by  mouth,  and  the  most  serious  method  is  the 
hypodermic.  Morphine  is  distinctly  more  dangerous,  more  domi- 
nating after  habituation,  than  the  other  forms.  It  is,  too,  more 
serious  in  its  effects  upon  the  general  health. 

Prognosis. — The  prognosis  is  not  good  and  except  in  such  cases 
as  are  not  complicated  by  neurotic  or  psychopathic  taint  or  dis- 
orders relieved  by  opium,  recovery  is  hardly  to  be  expected. 

Pathology. — Opium  has  much  less  tendency  to  produce  tissue 
degeneration  than  alcohol  and  many  persons  continue  for  years  to 
take  small  doses  with  little  apparent  harm. 

Treatment. — The  treatment  of  morphinism  has  to  do  with  the 
removal  of  the  drug  and  the  symptoms  of  abstinence.  Isolation 
is  more  necessary  than  in  alcoholism,  as  these  patients  make  more 
eflFort  to  obtain  their  accustomed  stimulant  surreptitiously.  It  is 
well,  in  accordance  with  Dercum's  suggestion,  not  to  begin  stop- 
ping the  drug  until  the  patient  has  been  under  treatment  for  a 
time,  confidence  established,  and  the  general  health  raised  to  the 
best  standard.  The  ration  de  luxe  can  then  be  rapidly  withdrawn, 
in  accordance  with  the  method  of  Erlenmeyer/^  leaving  the 

13  Erlenmeyer,  Albrecht :  On  the  Treatment  of  the  Morphine  Habit,  1889. 


236  OUTLINES   OF   PSYCHIATRY. 

patient  on  about  0.15  to  0.20  gm.  morphine  per  diem,  below  which 
amount  serious  symptoms  are  apt  to  present  themselves.  From 
this  point  on  the  withdrawal  should  be  gradual.  Symptoms  of 
abstinence,  if  they  appear,  are  referable  to  the  heart,  stomach, 
bowels  and  nervous  system ;  they  are  circulatory  failure,  respira- 
tory disturbance,  pyrosis,  vomiting,  diarrhea,  tremor,  general  de- 
bility, an  hallucinatory  delirium  and  sometimes  profound  collapse. 
Ball  has  called  attention  to  pollutions  and  erotomania  which 
may  result  from  abstinence.  For  the  cardiac  weakness  digitalis 
or  sparteine  hypodermically  should  be  used,  for  the  pyrosis,  bicar- 
bonate of  soda;  vomiting  and  diarrhea  should  be  treated  in  ac- 
cordance with  general  principles  (bismuth,  etc.),  opium  being 
avoided.  If  the  mental  and  physical  symptoms  become  grave 
morphine  should  be  given  and  will  usually  relieve  them.  The 
evening  dose  should  be  omitted  last,  to  combat  any  tendency  to 
insomnia,  and  full  feeding,  massage  and  hydrotherapy  are  valu- 
able adjuncts. 

Rapid  methods  of  withdrawal  associated  with  specific  vagotonic 
or  sympathicotonic  drugs,  calomel  and  beladonna  primarily,  when 
carefully  and  vigorously  carried  out  are  often  very  efficacious. 

Meco-narceine  (Duquesnel's  solution)  has  been  used  by  Jen- 
nings as  a  substitute  for  morphine  for  a  few  days  only  after 
entire  discontinuance.  Livingston's  solution  may  be  used  as  in 
alcoholism  (see  p.  233).  It  is  necessary  to  call  attention  to  the 
danger  of  cocaine  for  this  purpose.  Codeine  has  also  sunk  into 
disuse  and  the  synthetized  derivatives  of  morphine,  heroin,  dionin 
and  peronin  cannot  be  said  to  be  any  better.  Their  use  is  founded 
on  a  wrong  theory  and  is  fraught  with  danger.  Cases  of  serious 
addiction  to  codeine  and  heroin  have  been  reported.  Psycho- 
analytic treatment  is  fundamental. 

Cocaine. 

Cause. — Addiction  to  this  drug  has  in  a  great  many  cases  come 
about  by  attempting  to  substitute  it  for  morphine,  and  as  a  result 
pure  cases  of  cocainism  were  formerly  more  rare  than  at  present. 
Cocaine  has  been  used  so  much  of  late  in  dentistry,  minor  surgery, 
and  especially  nose  and  throat  work,  that  a  knowledge  of  it  has 
become  more  or  less  general.  The  victims  are  often  those  who 
have  commenced  its  use  for  its  analgesic  effects  and  are  frequently 
physicians. 


THE   TOXIC    PSYCHOSES.  237 

Symptoms. — The  symptoms  resulting  from  the  use  of  cocaine 
are  those  of  marked  stimulation.  The  pulse  is  increased,  pupils 
are  dilated.  The  patients  are  active  and  extremely  talkative, 
often  repeating  remarks  a  number  of  times;  they  are  constantly 
busy,  some  of  them  writing  endless  letters,  and  their  whole  ap- 
pearance indicates  an  acute  intoxication.  The  effects  are,  how- 
ever, very  fleeting  and  the  dose  has  to  be  frequently  renewed. 
Chronic  addictions  result  in  marked  emaciation,  cachectic  anemia, 
insomnia,  sometimes  epileptiform  attacks  and  various  paresthesias, 
the  most  marked  of  which  is  a  sensation  of  crawling  under  the 
skin  ("cocaine  bug").  In  the  psychic  sphere  occur  incapacity 
for  mental  application,  lessened  moral  sense,  mendacity,  irrita- 
bility, impaired  judgment  and  sometimes  the  delusion  of  marital 
infidelity.  These  symptoms  may  be  followed  by  mental  confusion 
with  hallucinations,  but  more  characteristically  by  a  paranoid  state. 
From  true  paranoia  this  is  differentiated  by  the  greater  variety 
of  delusions,  those  of  paranoia  being  less  variable,  rather  notice- 
able for  their  monotony.  In  the  paranoid  state  of  alcoholism,  on 
the  other  hand,  the  hallucinations  are  more  stereotyped. 

The  abstinence  symptoms  are  not  so  severe  as  with  morphine 
and  may  not  appear  for  several  days.  Erlenmeyer  has  called 
attention  to  a  profoundly  depressed,  lachrymose,  demoralized  con- 
dition, with  moaning  and  sighing  which  may  supervene.  The  per- 
secutory delirium  may  persist  for  a  long  time  and  constitute  the 
patient  a  very  dangerous  individual. 

Morphine  and  cocaine  addiction  may  also  activate  a  latent 
neuropsychopathic  state,  with  symptoms  of  psychasthenia — 
morbid  impulses,  insistent  ideas,  etc.  One  such  patient  suffered 
from  a  convulsive  tic  with  mental  depression  and  suicidal  im- 
pulse.    Recovery  followed  prolonged  abstinence. 

Treatment. — Isolation  should  be  insisted  upon.  The  drug  may 
be  withdrawn  rapidly  as  the  s}Tiiptoms  of  abstinence  are  not  as 
marked  as  in  morphine.  Livingston's  solution  may  be  used  (see 
p.  233).  Psychoanalysis  is  the  only  rational  therapy.  The 
prognosis  of  deprivation  is  good,  but  relapses  are  pretty  apt  to 
occur. 

Miscellaneous  Intoxicants. 

Various  other  drugs  may  produce  marked  mental  disturbances 
as  a  result  of  acute  or  chronic  poisoning  or  habituation.     The 


23 B  OUTLINES   OF   PSYCHIATRY. 

limits  of  this  work  permit  only  of  their  mention.  They  are 
chloral,  cannabis  indica,  somnal,  sulfonal,  aspirin,  paraldehyde, 
ether,  chloroform,  antipyrin,  phenacetin,  trional,  chloralamid, 
iodoform,  belladonna,  hyoscyamus,  salicylic  acid,  quinine,  the 
preparations  of  lead,  arsenic  and  mercury  and  the  bromides. 

It  should  be  realized  that  many  of  these  drugs  are  drugs  in 
common  use  and  that  unless  the  possibilities  of  their  producing 
a  psychosis  are  borne  in  mind  such  an  accident  may  arise  as  the 
result  of  large  doses  or  even  of  moderate  doses  in  especially  sus- 
ceptible persons.  It  is  just  such  cases  as  these,  together  with  the 
cases  that  arise  as  the  result  of  taking  several  drugs,  analgesics 
and  hypnotics,  that  one  meets  and  finds  that  no  suspicion  has 
arisen  as  to  the  true  cause  of  the  trouble.  Attention  has  been 
called  to  the  frequency  of  bromide  delirium  (O'Malley  and 
Franz,"  Casamajor^^).  Casamajor  has  called  particular  atten- 
tion to  the  frequency  with  which  bromide  delirium  is  produced  in 
the  treatment  of  alcoholism. 

The  character  of  the  delirium  in  these  cases  is  best  described  as 
dream-like.  The  content  of  the  delirious  experiences  remind  one 
of  delirium  tremens,  while  the  tendency  to  confabulation  reminds 
one  of  Korsakow's  psychosis.  The  patients  are  not  usually  appre- 
hensive and  restless  as  in  delirium  tremens,  but  more  composed 
and  may  be  dull  and  stupid,  though  there  are  not  infrequently 
outbreaks  of  violence  dependent  upon  paranoid  experiences.  The 
following  extracts  from  cases  will  illustrate  these  points : 

The  patient,  a  woman,  set.  36,  had  been  taking  morphine  hypodermically 
and  bromides,  chloral,  and  hyoscine  hydrobromate.  On  admission  saw 
men  in  rubber  garbs  who  stay  in  the  water  and  look  at  her  constantly. 
She  also  sees  the  king  and  queen,  bugs  and  snakes,  and  bull-dogs  with  huge 
open  mouths.  Says  the  king  and  queen  congratulated  her  when  she  picked 
up  the  broken  glass  at  F — 's  on  9th  St.  She  hears  bull-dogs  scream  and 
answers  imaginary  voices.  Electricity  is  played  on  her  by  Dr.  B —  and  she 
feels  snakes  which  crawl  about  her  neck.  Says  there  are  men  who  throw 
green  powder  about  the  room. 

Another  patient,  woman,  set.  38,  had  been  taking  antirheumatic  treatment 
with  aspirin  to  relieve  pain  and  later  morphine  and  hyoscine.  She  related 
the  following  delirious  experience  that  occurred  just  before  admission: 

1*  O'Malley  and  Franz :  A  Case  of  Delirium  Produced  by  Bromides,  Bul- 
letin No.  I,  Govt.  Hosp.  Insane. 

1^  Casamajor:  Bromide  Intolerance  and  Bromide  Poisoning,  Jour.  Nerv. 
and  Ment.  Dis.,  June,  191 1. 


THE   TOXIC    PSYCHOSES.  239 

"  I  believed  that  a  party  of  us  were  going  down  in  the  country  on  a 
picnic  and  that  a  cavalry  regiment  has  been  ordered  out.  When  we  got 
started,  we  found  that  a  whole  regiment  of  Indians  and  negroes  were  fol- 
lowing us.  We  went  to  the  place  in  the  country  where  I  was  bom  and 
brought  up,  and  there  we  found  a  hospital  which  was  to  be  used  for  caring 
for  us  until  the  negroes  and  Indians  were  allowed  to  kill  us.  The  patients 
in  the  hospital  were  all  in  little  beds  just  like  at  Providence  but  were  all 
sitting  up.  The  doors  were  locked  so  that  we  could  not  get  out,  but  I 
could  hear  the  negroes  and  Indians  talking  about  killing  us.  They  decided 
to  divide  the  party  up  and  take  us  to  their  different  camps.  They  also 
talked  of  blowing  the  hospital  up  with  dynamite.  They  talked  of  setting 
fire  to  a  haystack  that  was  situated  near  my  mother's  home.  I  heard  them 
preparing  fuse  which  was  to  be  used  in  exploding  the  dynamite.  I  was 
dreadfully  afraid  all  the  time  I  was  at  Providence  Hospital  and  felt  that 
I  was  among  enemies.  I  thought  the  nurses  were  trying  to  do  the  best 
they  could  for  me  but  that  they  were  in  the  employ  of  the  Indians  and 
negroes." 

Another  patient,  female,  aet.  ZT,  took  "  bromo-quinine "  for  two  weeks, 
when  she  developed  a  delirium.  The  following  is  the  substance  of  a  letter 
she  wrote  while  suffering  from  the  delirioid  experiences.  "  Just  go  there, 
I  cannot  talk,  I  am  under  a  terrible  spell,  I  do  not  know  what  it  is,  but  it 
is  the  most  wonderful  experience  I  ever  had.  I  am  hypo,  I  am  hypnotized. 
I  may  be  in  a  trance  for  three  months.  Do  not  for  God's  sake,  bury  me 
alive — Molly.  Keep  me  out  of  the  grave  four  or  five  months.  It  will  be 
all  right.  You  will  hear  some  things  that  will  surprise  you.  Ben,  go  in 
that  room  for  God's  sake,  there  is  a  man  in  there,  he  scares  everybody 
dumb,  I  cannot  talk,  but  for  God's  sake,  break  down  that  door.  Take 
Jack,  he  has  got  a  good  strong  arm,  break  that  door  down.  That  poor 
man  is  suffering,  I  saw  him  do  something  terrible,  and  it  awed  me  so  I 
am  half  paralyzed.    For  God's  sake,  break  that  door  down,  hurry  up." 

A  case  of  bromide  delirium  (reported  by  O'Malley  and  Franz)  had 
taken  on  an  average  300  grains  of  bromide  daily  for  fifteen  days.  Her  case 
illustrates  well  the  dream-like  character  of  the  hallucinatory  and  delusional 
experiences.  She  was  disoriented  on  admission.  Three  days  later  said  she 
had  spent  the  night  in  the  city,  was  with  a  large  crowd  of  men  and  women, 
that  her  husband  was  dead  and  that  she  had  seen  his  body  buried.  The 
next  day  asked  where  she  had  been  the  night  before  said,  "  I  was  over  to 
the  gypsy  camp;  I  went  over  in  northeast  Washington  and  saw  them  kill 
my  husband — smash  his  head;  his  brother,  who  is  a  sculptor,  made  a  form 
of  his  head ;  I  saw  it ;  he  will  be  buried  tomorrow."  A  few  minutes  later 
her  husband  visited  her.  She  told  him  she  thought  he  was  dead,  took  him 
to  task  severely  for  putting  her  in  the  hospital  and  being  unkind  to  her, 
but  throughout  the  visit  insisted  that  he  had  been  killed.  Six  days  after 
admission  she  still  had  visual  hallucinations — saw  cats  and  rabbits. 
Thought  some  of  the  women  patients  were  men,  thought  she  had  to  walk 
on  cat's  heads  when  she  left  her  bed  and  that  the  physicians  were  watch- 


240  OUTLINES   OF  PSYCHIATRY. 

ing  her  from  the  register  plate  in  her  room.     Later  she  complained  that 
she  was  "  spirited  away  every  night  by  some  influence." 

In  the  treatment  of  these  cases  the  principal  thing  is  the  re- 
moval of  the  drug,  though  often  the  underlying  condition,  for 
which  the  drug  was  taken — pain,  insomnia — must  then  be  treated. 
It  must  be  borne  in  mind  that  it  may  take  several  weeks  for  the 
patient  to  clear  up  after  all  drugs  are  discontinued. 


CHAPTER   XV. 

Psychoses  Associated  with  Organic  Diseases  and  Injury 
OF  THE  Brain. 

Epilepsy. — The  word  epilepsy  does  not  stand  for  any  one  well 
defined  somatic  disease,  but  includes  a  series  of  end  results,  con- 
ditioned by  a  multiplicity  of  pathological  conditions  of  the  brain. 
It  is  really  more  proper  to  avoid  its  use  altogether  unless  it  is 
limited  to  a  special  group  of  cases  (i.  e.,  the  cases  with  disease  of 
Ammon's  horn  as  suggested  by  Alzheimer)  and  speak  of  the 
epilepsies. 

Convulsions  may  occur  in  a  great  variety  of  conditions,  i.  e., 
the  functional  psychoneuroses  (hysteria),  toxemias  (alcohol, 
uremia),  organic  brain  disease  (tumor,  softenings,  paresis),  de- 
fects of  cerebral  development  (idiocy).  Those  occurring  late  in 
life  are  generally  dependent  upon  some  organic  changes,  such  as 
cerebral  arteriosclerosis  or  upon  toxemias  and  are  for  conveni- 
ence often  spoken  of  as  late  epilepsies  in  distinction  from  those 
epilepsies  which  occur  in  early  life  and  which  are  correspondingly 
known  as  early  epilepsies. 

The  form  of  epilepsy  dealt  with  here  is  that  form  ordinarily 
known  as  idiopathic  epilepsy,  i.  e.,  epilepsy  which  is  not,  appar- 
ently at  least,  symptomatic  of  some  other  condition.  The  mental 
disturbances  associated  with  and  due  to  epilepsy  may  be  consid- 
ered as  divided  into  the  paroxysmal  and  the  interparoxysmal. 

Paroxysmal. — The  most  characteristic  and  almost  invariable 
mental  disturbance  due  to  epilepsy  is  the  unconsciousness  asso- 
ciated with  the  convulsion.  This  may  be  very  transitory  or  may 
pass  into  a  deep  stupor  of  some  hours'  duration. 

In  a  great  many  epileptics  there  is  a  marked  disturbance  pre- 
ceding the  convulsion,  sometimes  of  several  days'  duration,  and 
those  who  are  accustomed  to  the  patient  can  tell  that  a  fit  is  im- 
pending. This  change  manifests  itself  in  increased  irritability, 
complaining,  sometimes  by  depression  or  dullness,  and  there  may 
be  associated  disturbances  of  the  sensorium,  hypochondriacal  com- 

241 


242  OUTLINES  OF  PSYCHIATRY. 

plaints  and  hallucinations.  All  these  conditions  are  commonly 
promptly  relieved  by  the  fit. 

Immediately  after  the  convulsion  there  is  often  a  temporary 
condition  of  confusion.  The  patient  rises  clumsily,  looks  about 
him  in  a  bewildered  manner  and  often  does  some  semi-automatic 
acts,  such  as  taking  off  his  clothes. 

Just  before  or  more  commonly  after  the  convulsion  a  condition 
of  active  excitement  may  occur  v^^hich  may  reach  the  stage  of 
frenzy.  In  this  state  the  patient  is  a  veritable  wild  man — epi- 
leptic furor.  He  is  liable  to  kill  anyone  who  approaches  or  even 
himself.  Fortunately  his  efforts  are  diffuse  and  not  coherently 
directed.  During  this  attack,  which  is  usually  brief,  he  has  to  be 
restrained  and  at  the  end  is  quite  completely  exhausted. 

An  attack  of  mental  disturbance  may  take  the  place  of  the  con- 
fusion and  thus  become  an  epileptic  equivalent.  These  attacks  of 
psychic  epilepsy  frequently  take  the  form  of  so-called  epileptic 
automatism  or  epileptic  dream  states.  In  this  condition  the  patient 
may  do  almost  anything  and  when  he  comes  to  himself  he  has 
absolutely  no  recollection  of  what  has  happened.  Usually  the 
attacks  are  of  short  duration  and  the  acts  rather  simple — more 
simple  than  in  the  dream  states  of  alcohol  or  hysteria.  However, 
they  may  last  for  days,  all  sorts  of  things  may  be  done,  crimes 
may  even  be  committed,  so  that  the  condition  often  becomes  of 
great  medico-legal  importance.  The  crimes  of  violence  are  often 
noted  for  their  ferocity  and  brutality. 

It  must  not  be  forgotten  that  these  states  may  be  associated 
with  a  seizure  that  was  so  slight  as  not  to  have  been  noticed.  Evi- 
dences of  such  a  seizure,  especially  in  medico-legal  cases,  should 
always  be  looked  for. 

Transitory  conditions  of  depression,  excitement,  confusion  and 
stupor  may  develop  and  quite  characteristically  a  condition  of 
ecstasy  with  hallucinations.  The  patient  sees  the  gates  of  heaven 
open  and  as  the  heavenly  hosts  appear  he  hears  himself  addressed 
by  the  voice  of  God. 

Interparoxysmal. — The  interparoxysmal  condition  constitutes 
in  the  main  the  epileptic  character.  The  epileptic  is  apt  to  be 
morose,  irritable,  suspicious  and  hypochondriacal.  He  is  quite 
characteristically  unreliable  and  with  it  all  frequently  presents 
a  very  aggressive  form  of  sentimental,  shallow  religiosity.     While 


PSYCHOSES   ASSOCIATED   WITH    OTHER   DISEASES.  243 

we  do  find  good-natured,  even-tempered,  well-disposed  epileptics, 
they  are  more  apt  to  be  most  difficult  problems  to  get  along  with, 
and  as  a  class  in  the  hospital  they  are  extremely  difficult  to  care 
for.  Passing  attacks  of  mental  disturbance  occur  in  the  inter- 
paroxysmal  period  without  apparent  relation  to  seizures.  Attacks 
of  transitory  ill-humor,  according  to  Aschaffenberg,  occur  in  78 
per  cent,  of  cases.  This  is  a  condition  of  irritability,  unreason- 
ableness, sometimes  associated  with  delusions  and  hallucinations. 
The  patient  is  in  a  noli  me  tangere  state  and  very  apt  to  get  into 
quarrels  or  make  attacks.  Rarely  the  disturbance  is  expansive  in 
type  and  in  these  cases  may  be  associated  with  religious  fervor. 

A  study  of  the  sexual  characteristics  of  epileptics  has  recently 
been  made  by  Maeder.^  As  a  result,  he  finds  the  sexuality  of 
the  epileptic  still  largely  undeveloped,  still  only  little  removed 
from  the  infantile  stage.  The  sexual  feelings  are  very  prominent 
and  are  aroused  in  many  ways:  autogenically,  constituting  auto- 
erotism, and  giving  rise  to  such  phenomena  as  masturbation,  and 
by  stimuli  from  without,  constituting  alloerotism,  which  gives  rise 
to  a  normal  libido  (heterosexuality),  homosexuality,  exhibition- 
ism, etc.  Maeder  uses  the  term  polyvalent  to  describe  this  char- 
acteristic of  the  epileptic  sexuality  which  permits  it  to  be  aroused 
by  many  kinds  of  excitants. 

The  epileptic  state  leads  in  a  certain  proportion  of  cases,  if  it 
has  begun  in  early  life,  to  conditions  of  feeble-mindedness,  im- 
becility, and  idiocy,  or,  depending  upon  the  same  causes,  is  asso- 
ciated with  these  conditions.  Epilepsy  tends,  in  many  cases,  to 
produce  a  general  mental  deterioration — epileptic  dementia — 
which  may  become  very  profound. 

The  Seizure. — There  are  many  grades  of  severity  of  the  attack 
running  all  the  way  from  the  severe  grand  mal  seizure  to  slight 
disturbances  without  loss  of  consciousness.  There  are  probably  a 
continuous  series  of  convulsive  phenomena  from  light  to  severe. 

The  lightest  form  of  convulsive  seizure  is  represented  by  the 
hysterical  attack,  psychogenic  in  origin,  consciousness  nor  pro- 
foundly disturbed.  Next  in  grade  of  severity  but  still  within 
strictly  psychological  levels  are  the  psychasthenic  convulsions  of 
Oppenheim   (compulsion  neurosis  type).     Then  come  the  epi- 

1  Maeder :  Sexualitat  und  Epilepsie,  Jahrb.  f .  psychoanalitische  u.  psy- 
chopathologische  Forschungen,  1909. 


244  OUTLINES   OF   PSYCHIATRY. 

lepsies  of  Bratz  and  Leubuscher  which  are  situation  reactions 
(prison  psychosis)  and  while  still  psychological  indicate  a  more 
seriously  burdened  personality.  Following  these  come  the  con- 
fessedly epileptic  types. 

As  this  series  indicates  the  psychological  components  have  been 
much  emphasized  of  late. 

Diagnosis. — It  must  be  recalled  that  epilepsy  is  no  longer  con- 
sidered as  a  disease  but  that  the  term  as  used  covers  a  group 
of  conditions  which  differ  widely  from  one  another.  The  above 
descriptions  were  intended  to  apply  only  to  genuine,  or  what  used 
to  be  called  idiopathic,  epilepsy. 

In  addition  to  genuine  epilepsy,  which  usually  begins  early  in 
life — early  epilepsy — various  late  epilepsies  have  been  described. 
The  principal  of  these  are  the  toxic  (alcohol,  lead),  the  arterio- 
sclerotic (post-hemiplegic) ,  the  syphilitic  and  the  traumatic. 
Many  epileptiform  attacks  are  very  similar  to  genuine  epilepsy, 
such,  for  example,  as  uremic  convulsions,  paretic  seizures  and 
sometimes  hysteria,  while  the  various  functional  conditions,  par- 
ticularly hysteria  (sometimes  psychasthenia),  should  be  borne  in 
mind. 

Never  forget  the  possibility  of  exclusively  nocturnal  attacks — 
nocturnal  epilepsy.  Always  be  suspicious  of  the  patient  who 
awakes  tired  and  lame  as  if  his  muscles  had  been  beaten,  particu- 
larly if  he  shows  conjunctival  ecchymoses,  a  wounded  tongue,  and 
flecks  of  blood  on  the  pillow.  A  localized  muscular  weakness  that 
passed  off  promptly  would  add  certainty  to  the  diagnosis. 

Recently  Scripture  and  Clark^  have  described  the  epileptic 
voice  sign  and  found  it  in  75  per  cent,  of  cases.  The  voice  has 
been  studied  by  the  "  air  puff  "  method  of  recording  on  the  kymo- 
graph. A  measure  of  the  waves  gives  the  rates  of  vibration.  A 
line  connecting  the  tops  of  the  ordinates  produces  the  "melody 
plot."  Normally  each  vowel  has  a  rising  and  falHng  melody.  In 
epilepsy  the  vowels  run  along  on  an  even  tone — "  plateau  speech." 
This  is  very  characteristic  and  easily  recognized. 

Pathology. — The   following  groups  of  epilepsy  are  given  by 

2  Scripture  &  Clark :  Researches  on  the  Epileptic  Voice.  Proc.  N.  Y. 
Neurol.  Soc.,  Nov.  12,  1907. 


PSYCHOSES   ASSOCIATED   WITH    OTHER   DISEASES.  245 

Alzheimer^  as  a  result  of  the  histological  examination  of  63 
cases : 

A.  Cases  with  very  obscure  etiology  (genuine  epilepsy). 

1.  This  group  comprises  60  per  cent,  of  the  cases. 

a.  with  sclerotic  changes  in  Ammon's  horn. 
h.  with  superficial  gliosis  of  the  hemispheres. 
c.  with  signs  of  an  acute  process  (status)  besides 
a  and  b. 

2.  This  group  comprises  4  per  cent,  of  the  cases.     A 

process  that  can  be  called  atrophic  sclerosis;  con- 
siderable atrophy  of  different  regions;  no  important 
changes  in  the  vessels;  deep  impairment  of  the 
nervous  structures,  especially  the  third  cell  layer  of 
the  cortex. 

B.  Cases  due  to  external  poisons. 

1.  Alcohol:  Different  anatomical  changes  as  in  chronic 

alcoholism.  Besides  these  sometimes  acute  changes 
as  in  delirium. 

2.  Lead:  Different  changes.     Experimentally  lead  pro- 

duces a  genuine  encephalitis. 

C.  General  diseases. 

1.  Syphilis:  Different  forms  of  brain  syphilis.     Espe- 

cially the  endarteritis  of  the  finer  vessels  (Nissl, 
Alzheimer). 

2.  Arteriosclerosis. 

D.  Focal  diseases :  Most  of  the  cases  in  this  group  are  cases 

of  epilepsy  with  idiocy  after  encephalitis. 

E.  Arrests  of  development : 

1.  Stadium  verrucosum  (Rancke) — microgyria. 

2.  Sclerosis  tuberosa. 

Treatment. — The  treatment  is  the  treatment  of  epilepsy.  When 
dangerous  tendencies  are  associated  with  the  attacks  the  patient 
should  be  confined  in  an  appropriate  institution. 

Tumor. — Mental  symptoms  are  more  apt  to  occur  when  the 
tumor  is  located  in  the  prefrontal  region.  They  are  change  of 
character,  irritability,  childishness,  emotional  instability,  with  a 

3  Alzheimer  und  Vogt :  Die  Gruppierung  der  Epilepsia,  Jahresversamm- 
lung  des  deutschen  Vereins  fiir  Psychiatrie,  1907;  Ref.  Allg.  Ztschr.  f. 
Psych.,  Bd.  64,  1907. 


246  OUTLINES   OF   PSYCHIATRY. 

tendency  to  hebetude  and  some  clouding  of  consciousness.  Hal- 
lucinations may  develop  as  the  result  of  the  invasion  by  the 
growth  of  sensory  areas.  Tumors,  especially  of  the  frontal  region, 
are  sometimes  associated  with  a  jovial,  happy  frame  of  mind  and 
a  tendency  to  joke  and  make  fun.  This  symptom  has  been  given 
the  name  Witselsucht  by  the  Germans. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  the 
classical  symptoms  of  tumor  and  a  study  of  the  localizing  signs. 
The  disease  most  apt  to  be  confounded  with  tumor  is  paresis. 
Cases  are  seen  on  the  one  hand  to  present  quite  clear  local  symp- 
toms and  subsequently  turn  out  to  be  paresis ;  while  on  the  other 
hand  cases  are  seen  without  local  symptoms  and  which  appear  to 
be  paresis  but  which  turn  out  to  be  tumor. 

S5^hilis. — An  acute  delirium  may  develop  during  the  early  sec- 
ondary manifestations  of  the  disease.  Later  marked  manifesta- 
tions may  be  connected  with  local  or  general  disease  of  the  brain. 
Gumma  are  rare  and  give  the  symptoms  of  tumor.  The  most 
common  condition  is  a  progressive  disease  of  the  cerebral  vessels, 
often  with  thrombosis. 

The  mental  symptoms  are  those  of  dementia,  to  which  are  added 
local  symptoms  as  a  result  of  thrombosis.  The  symptoms  will  of 
course  vary  according  to  the  location  of  the  softening. 

Plaut*  in  a  suggestive  study  classifies  the  s>philitic  psychoses 
as  follows:  (i)  Simple  luetic  weakness  of  mind — generally  ac- 
companied by  hemiplegia  or  monoplegia,  which  may  be  transitory 
or  permanent.  (2)  Syphilitic  pseudo-paralysis — the  presence  of 
hallucinations  of  hearing  have  great  weight  in  the  diagnosis  of  this 
form  and  speak  against  true  paresis.  (3)  Paranoid  forms  com- 
bined with  tabes — remaining  stationary  for  long  periods,  little 
dementia,  rarely  delusions  of  persecution,  numerous  hallucinations 
of  hearing,  disturbances  of  common  sensation.  (4)  Paranoid 
forms  without  tabetic  symptoms,  for  example,  with  auditory  hal- 
lucinations and  delusions  of  jealousy.  (5)  Certain  epileptic 
forms,  due  to  endarteritic  changes.  (6)  Short  hallucinatory  con- 
fused states.  (7)  Psychotic  disturbances  associated  with  syphi- 
litic cardiac  disease,  observed  also  as  a  result  of  syphilitic  aortitis. 
(8)    Psychoses  resembling  manic-depressive  psychosis,  particu- 

*  Plaut,  F. :  Die  luetischen  Geistesstorungen,  Centralb.  f.  Nervenh.  und 
Psych.,  XXXII. 


PSYCHOSES   ASSOCIATED   WITH    OTHER   DISEASES.  247 

larly  manic  excitement.  (9)  Mental  disorder,  due  to  syphilis  as  a 
psychic  trauma.  (10)  Various  grades  of  weak-mindedness, 
psychopathic  constitution,  etc. 

Diagnosis. — Many  of  these  cases  are  extremely  difficult  to  dif- 
ferentiate from  paresis.  Vascular  brain  syphilis  occurs  a  shorter 
period  after  luetic  infection,  the  patient  is  younger,  it  is  more 
marked  by  localizing  symptoms,  often  is  associated  with  severe 
headaches,  which  are  usually  worse  at  night,  and  the  symptoms, 
with  the  exception  of  those  due  to  destructive  lesions,  may  yield 
to  anti-syphilitic  medication.  A  most  careful  neurological  ex- 
amination is  of  the  first  importance. 

Pathology. — ^According  to  Alzheimer^  syphilitic  affections  of 
the  brain  show  the  following  anatomical  forms : 
I.  Isolated  gummatous  tumors. 
II.  Extensive   meningitic   infiltrations    (meningo-encephali- 
tis),  with  or  without  gummatous  nodules. 

(a)  Of  the  base. 

(b)  Of  the  convexity. 

Cases  involving  both  base  and  convexity  are  rare. 
III.  Endocarditis  luetica. 

(a)  Heubner's  endarteritis. 

(b)  NissL  and  Alzheimer's  endarteritis  of  the  smaller 

vessels. 
Number  II   (meningo-encephalitis)  is  the  most  apt  to  be 
mistaken  for  paresis. 
A  spirochseta  septicemia  may  also  occur. 

It  must  not  be  forgotten  that  parenchymatous  and  vascular 
changes  may  be  found  in  the  same  brain. 

Apoplexy. — The  mental  condition^  following  apoplexy  is  usually 
one  of  impairment  which,  if  the  lesion  is  considerable,  progresses 
to  marked  dementia.  If  the  softening  involves  the  speech  area, 
especially  if  it  produce  sensory  aphasia,  the  demenia  is  much 
more  rapid  in  progress,  as  it  must  be  remembered  that  these 
patients  are  often  senile.  Epilepsy  often  develops  as  a  result  of 
a  localized  area  of  softening.     These  patients  often  express  an 

^  Alzheimer :  Histologische  Studien  zur  Differentialdiagnose  der  Pro- 
grassive  Paralyse,  Histol.  u.  histopath.  Arbeiten,  Bd.  I,  1904. 

<■•  Ricksher,  Charles :  A  Review  of  the  Mental  Symptoms  Accompanying 
Apoplexy,  Am.  Jour,  of  Insanity,  July,  1906. 


248  OUTLINES  OF  PSYCHIATRY. 

exaggerated  emotivity  sometimes  on  being  asked  the  simplest 
question. 

The  neurological  signs  of  hemiplegia  are  present,  also  often  the 
signs  of  senility  and  not  infrequently  of  arteriosclerosis. 

Traumatism. — The  most  frequent  symtpoms  following  trauma 
are  those  of  hysteria  and  neurasthenia.  Dementia  precox,  manic- 
depressive  psychosis  and  paresis  may  follow  an  injury. 

After  the  injury  a  delirium  may  develop.  Aside  from  this, 
mental  symptoms  may  not  occur  for  a  considerable  time,  and 
when  they  do  they  usually  consist  of  an  apathetic  dementia,  often 
with  irritability.  There  are  often  memory  defects,  especially 
amnesia  for  the  time  of  the  injury,  and  these  defects  may  be 
filled  in  with  fabrications.  There  is  almost  always  intolerance 
of  alcohol. 

Meyer'^  classifies  the  eflfects  of  traumatism  in  the  nervous  sys- 
tem as  follows: 

1.  The  direct  focal  and  the  more  diffuse  destruction  of  the 
nerve-tissue  or  of  parts  of  it ;,  and  the  reaction  of  the  tissues. 

(a)  The  immediate  effects^ — edema. 
{b)  The  scar  formation. 

2.  The  distinctly  diffuse  commotions  in  which  the  general  reac- 
tion and  the  psychic  elements  preponderate,  including  the  remote 
active  results  of  exaggerations  of  vasomotor  and  emotional 
responsiveness. 

He  classifies  the  psychoses  developing  as  follows: 

1.  Post-traumatic  deliria,  including  febrile  reactions,  the  delir- 
ium nervosum  of  Dupuytren,  not  differing  from  post-operative 
delirium,  the  delirium  of  the  slow  solution  of  coma  in  alcoholic 
as  well  as  non-alcoholic  subjects,  protracted  deliria  with  confabu- 
lation with  or  without  alcoholic  or  senile  basis. 

2.  Post-traumatic  Constitution. — Excessive  reaction  to  alcohol, 
la  grippe,  etc.,  the  vasomotor  neurosis  of  Friedman,  the  "explo- 
sive diathesis  "  of  Kaplan,  hysteroid  or  epileptoid  episodes,  with 
or  without  convulsions,  paranoid  states. 

3.  Traumatic  Defect  Conditions. — Conditions  allied  to  aphasia, 
deterioration  wtih  epilepsy,  deterioration  due  to  the  progressive 

"Meyer,  Adolf:  The  Anatomical  Facts  and  Clinical  Varieties  of  Trau- 
matic Insanity,  Am.  Jour.  Insanity,  Jan.,  1904. 


PSYCHOSES  ASSOCIATED  WITH   OTHER  DISEASES.  249 

alteration  of  the  primarily  injured  parts,  with  or  without  arterio- 
sclerosis. 

4.  Psychoses  in  which  trauma  is  merely  a  contributory  factor. — 
Paresis,  manic-depressive,  dementia  procox. 

5.  Traumatic  psychoses  from  injury  not  directly  affecting  the 
head. 

To  state  the  case  simply  there  are  certain  transitory  conditions 
of  delirioid  experiences  following  trauma  which  may  have  a  per- 
manent constitutional  change  or  not.  Then  there  are  certain  ver}' 
slowly  progressive  dementias  which  can  only  be  appreciated  by 
taking  a  longitudinal  section  of  the  patient's  life.  Thus  is  will  be 
found  that  a  life  that  has  been  efficient  up  to  a  certain  point  w^here 
it  was  punctuated  by  the  trauma  has  fallen  off  in  efficiency  pro- 
pressively  since.  Then  there  are  the  endogenous  psychoses  for 
which  the  trauma  may  be  only  the  exciting  cause.^ 

This  group  of  the  traumatic  psychoses  includes  also  the  post- 
operative psychoses,  the  psychoses  following  operations  on  the 
eye,  ophthalmic  psychoses,  and  insomnia  psychoses. 

8  Glueck :  Traumatic  Psychoses  and  Post-Traumatic  Psychopathic  States, 
Jour.  Am.  Med.  Ass.,  April  i,  191 1. 


17 


CHAPTER  XVI. 

The  Symptomatic  Psychoses. 

In  this  group  of  symptomatic  psychoses  are  included  those 
mental  disorders  that  are  associated  with  and  are  symptomatic  of 
various  bodily  diseases.  Bonhoeffer^  includes  in  this  group  the 
psychoses  of  the  infections  and  of  fever  delirium  and  defer- 
vescence. 

Auto-toxic  Psychoses. 

Uremia. — The  auto-intoxication  which  develops  as  a  result  of 
renal  disease  produces  mental  symptoms  of  an  acute  confusion 
with  changeable  delusions,  hallucinations,  clouding  of  conscious- 
ness, restlessness,  and  often  an  occupation  delirium.  The  char- 
acter of  the  delusions  may  be  more  or  less  consistently  grandiose, 
giving  rise  to  an  expansive  form,  or  depressive,  giving  rise  to  the 
depressive  form.  In  subacute  cases  a  condition  of  suspicion, 
anxiety,  with  loosely  systematized  delusions  of  persecution,  some- 
times develop. 

It  must  not  be  forgotten  that  in  some  cases  of  acute  uremia  dis- 
tinctly focal  symptoms  develop.  These  cases  associated  with 
headache,  vomiting,  and  dimness  of  vision,  often  closely  resemble 
brain  tumor. 

The  uremic  convulsions  cannot  be  distinguished  in  appearance 
from  the  epileptic  and  development  afterwards  of  a  dream  state 
makes  the  resemblance  closer  still. 

Here,  as  in  all  toxic  conditions,  the  characteristic  dream-like 
hallucinatory  delirium,  which  has  been  called  "cinematographic," 
is  the  characteristic  mental  symptom  (for  examples  see  alcohol). 

Diagnosis. — The  diagnosis  is  to  be  made  from  the  association 
of  an  acute  confusion  with  the  uremic  state.  The  subacute  cases 
may  mislead  as  they  have  the  outward  semblance  of  a  chronic 
psychosis.  The  history  will,  however,  show  an  acute  onset  and 
the  physical  examination  will  disclose  evidences  of  renal  disease. 

Diabetes. — The  mental   disorder   associated  with   diabetes  is 

^  Bonhoeffer :  Die  Symptomatischen  Psychosen. 

250 


THE   SYMPTOMATIC   PSYCHOSES.  2$  I 

usually  of  a  mild  chronic  type.  It  is  usually  a  depression,  with 
melancholic  ideas  of  sin,  ruin  and  usually  also  hypochondriacal 
ideas,  especially  with  reference  to  the  excretion  of  sugar.  There 
is  liable  to  be  marked  somnolence  with  some  confusion  and  dis- 
orientation in  the  semi-somnolent  state.  Persecutory  delusions 
are  quite  frequently  developed,  ideas  of  poisoning  and  the  like. 

It  must  be  remembered  that  diabetes  produces  arteriosclerosis, 
so  that  certain  of  the  mental  symptoms  may  depend  upon  the 
degenerative  changes  in  the  cerebral  vessels. 

Diagnosis. — The  persecutory  type  must  be  differentiated  from 
the  chronic  psychoses.  Otherwise  the  diagnosis  is  made  by  the 
association  of  the  mental  symptoms  with  glycosuria.  A  diabetic 
pseudo-general  paresis  has  been  described. 

Gastro-Intestinal. — Certain  cases  of  acute  confusion  develop, 
associated  with  a  profuse,  offensive  diarrhea,  a  high  grade  of 
indicanuria,  vomiting,  low  fever  and  perhaps  mild  albuminuria. 
Some  of  these  cases  go  on  to  acute  delirium,  with  high  fever, 
typhoid  state,  profound  exhaustion,  coma  and  death. 

Thyroigenous  Psychoses. 

The  thyroigenous  psychoses  may  be  divided  in  two  classes : 
Those  due  to  defect  of  secretions — myxoedema  and  cretinism — 
and  those  due  to  hypersecretion — exophthalmic  goitre. 

Myxoedema. — Associated  with  the  physical  symptoms  of  my:xce- 
dema  is  a  mental  state  of  stupidity,  indifference  and  apathy,  deep- 
ening into  dementia.  There  is  gradual  failure  of  memory,  lack 
of  power  of  voluntary  attention,  slow  association  of  ideas  and 
difficulty  of  apprehension.  Sometimes  a  moderate  degree  of  con- 
fusion with  excitement  develops. 

Cretinism. — Associated  with  the  physical  signs  of  cretinism  is 
a  mental  state,  due  to  lack  of  development,  which  may  range  all 
the  way  from  the  profound  degradation  of  idiocy  to  mild  grades 
of  imbecility. 

Exophthalmic  Goitre. — The  prevailing  mental  tone  associated 
with  this  disease  is  fear  and  apprehension. 

It  is  not  infrequently  associated  with  hallucinations  of  hearing 
and  vision;  voices  may  be  heard  saying  disagreeable  things. 
With  these  hallucinations  occur  anxious  and  agitated  states.  The 
prognosis  in  these  cases  is  bad.     Many  of  them  die. 


252  OUTLINES   OF   PSYCHIATRY. 

Severe  cases  of  acute  thyroidism  with  active  delirium  are  occa- 
sionally seen  following  operations  upon  the  gland  and  may  be  due 
to  the  expression  of  its  secretions  by  handling  it  and  subsequent 
absorption. 

Nervous  Diseases. 

Sydenham's  Chorea. — Patients  with  chorea  are  usually  impa- 
tient, irritable,  fretful  and  emotionally  unstable.  Some  of  the 
cases  develop  terrifying  dreams  and  hallucinations,  especially  at 
night.  Marked  psychotic  symptoms  develop  in  the  variety  of  the 
disease  known  as  chorea  insaniens,  an  acute  confusion,  sometimes 
of  violent  type,  develops  with  hallucinations  and  often  a  paranoid 
condition  with  delusions  of  persecution.  Sometimes  a  condition 
of  stupor  is  observed. 

Korsakow's  psychosis  is  sometimes  seen  as  a  result  of  poly- 
neuritis from  overtreatment  with  arsenic. 

Diagnosis. — The  diagnosis  is  made  by  the  association  of  the 
mental  symptoms  with  the  characteristic  choreic  movements. 

Huntington's  Chorea. — This  disease  is  associated  on  the  psy- 
chical side  with  gradual  mental  impairment. 

Paralysis  Agitans. — This  disease  is  often  associated  with  a 
mild  degree  of  mental  enfeeblement. 

Multiple  Sclerosis. — The  mental  condition  is  usually  one  of 
slight  impairment,  especially  with  emotional  instability.  The  pa- 
tient laughs  and  cries  very  easily. 

Diagnosis. — The  disease  must  be  differentiated  from  paresis 
which  it  often  closely  resembles. 

Polyneuritis. — See  Korsakow's  Psychosis,  Chapter  XIV. 

Pellagra. — There  has  been  some  study  of  the  mental  symp- 
toms of  pellagra  of  late  years.  From  the  few  cases  I  have  seen 
and  from  talking  with  those  who  have  had  it  under  observation 
there  seems  to  be  a  variety  of  symptom  pictures. 

Many  cases  present  no  nervous  or  mental  symptoms  at  all.  In 
those  who  do  there  seems  to  be  a  tendency  toward  a  variable 
localization  of  the  disease  process.  There  seem  to  be  cases  in 
which  the  spinal  cord  suffers  most  and  others  in  which  the  brain 
suffers  most.  In  this  latter  group  a  condition  of  very  acute 
delirium  may  be  developed  running  a  rapid  course  to  fatal  termi- 
nation and  reminding  one  of  the  acute  forms  of  paresis.     The 


THE   SYMPTOMATIC   PSYCHOSES.  253 

more  frequent  condition,  of  which  I  have  seen  a  number  of  cases, 
seems  to  be  more  in  the  nature  of  a  simple  retardation.  The  pa- 
tient moves  slowly  or  not  at  all,  and  answers  questions  after  a 
long  delay  in  a  low  tone  of  voice  and  in  monosyllables.  There 
does  not  go  with  this  retardation  however  an  emotional  depression 
as  in  melancholia.  I  have  also  seen  pellagra  phobia  in  an  infected 
territory. 

With  this  disease,  as  with  many  others,  we  must  not  forget  that 
it  may  be  associated  with  various  psychoses  without  having  any 
other  relation  to  them.  This  is  particularly  so  in  this  country  as 
the  large  groups  of  cases  which  have  occurred  have  been  in  hos- 
pitals for  the  insane. 

Perhaps  Gregory  has  made  the  most  careful  recent  clinical 
study  of  the  mental  symptoms.  He  considers  his  cases  under  the 
following  seven  categories:  (i)  Pellagrous  neurasthenia,  (2) 
stuporous  group,  (3)  mental  aberration,  (4)  acute  delirium,  (5) 
katatonia,  (6)  anxiety  psychosis,  (7)  manic-depressive  group. 
It  does  not  seem  clear  however  just  what  is  the  connection  in  all 
of  these  cases  between  the  pellagra  and  the  psychosis. 

Heart  Disease. — Depressive  states  are  most  in  evidence  here. 
Mental  symptoms,  however,  are  most  apt  to  be  associated  with 
failure  of  compensation.  With  precordial  distress  goes  typically 
a  mental  state  of  anxiousness.  Transitory  confusions  with 
dreamy  hallucinations  occur  with  compensation  disturbances  and 
edema. 

Treatment. — The  treatment  of  all  these  conditions  is  the  treat- 
ment of  the  underlying  disease. 

Diseases  Other  than  Nervous. 

Various  other  diseases  have  from  time  to  time  mental  symptoms 
associated  with  them.  The  great  majority  of  such  diseases,  if  not 
all  of  them,  have  elements  of  infection  or  toxemia  and  exhaustion 
combined  with  or  part  of  them.  We  therefore  see  the  mental 
symptom-complex  of  confusion  arise  most  typically.  In  some 
cases,  especially,  the  less  acute  paranoid  conditions  occur  and  hal- 
lucinoses  are  of  occasional  occurrence. 

2  Gregor,  A. :  Beitrage  zur  Kenntnis  der  pellagrosen  Geistesstorungen, 
Jahrb.  f.  Psychiat.  u.  Neurol.,  1907. 


254  OUTLINES   OF   PSYCHIATRY. 

Head  has  shown  that  certain  visceral  diseases,  especially  of 
cardiovascular  and  pulmonary  origin,  often  have  associated  men- 
tal symptoms,  although  they  may  not  appear  except  on  the  most 
careful  examination.  The  symptoms  found  are:  (i)  Hallucina- 
tions of  vision,  hearing  and  smell;  (2)  moods,  either  of  depression 
or  exaltation,  and  (3)  suspicions  usually  occurring  when  a  de- 
pression has  persisted  for  some  time. 

These  conditions  take  their  origin  as  a  result  of  reflected  vis- 
ceral pains.  Each  spinal  segment  has  both  a  visceral  and  a 
cutaneous  representation.  Disease  occurring  in  the  visceral  area 
is  referred  to  the  cutaneous  surface  supplied  by  the  same  segment. 
The  cutaneous  distribution  of  the  fifth  nerve  corresponds  to  the 
visceral  distribution  of  the  vagus,  so  pain  occurring  in  the  vagus 
territory  will  be  referred  to  the  scalp  and  thus  occur  points  ot 
tenderness  in  this  region  with  which  the  hallucinations  are  asso- 
ciated. The  mood  of  exaltation  is  essentially  transitory  and  arises 
as  a  contrast  phenomenon  of  the  depression  and  as  a  result  of  the 
disappearance  or  lessening  of  the  reflected  somatic  pain. 


CHAPTER  XVII. 

Borderland  and  Episodic  States. 
The  Psychoneuroses. 

Neurasthenia. — Symptoms:  The  manifestation  of  neurasthenia 
are  protean  and  numerous.  The  disease  may  be  on  a  hereditary 
basis  constituting  so-called  constitutional  neurasthenia,  or  it  may  be 
acquired  by  exhausting  and  debilitating  conditions,  usually  acting 
over  a  considerable  period.  Symptoms  of  hysteria  are  not  infre- 
quently combined  with  those  of  neurasthenia,  constituting  hystero- 
neurasthenia.  Neurasthenia  is  usually  classified  in  accordance 
with  the  organs  about  which  the  symptoms  most  prominently 
group  themselves  into  cerebral,  spinal,  genital,  gastric,  angio- 
pathic,  or  in  accordance  with  the  cause  as  lithcemic  and  traumatic. 

The  fundamental  symptom  of  neurasthenia  is  fatigueability, 
both  mental  and  physical.  With  this  fatigueability  there  goes  a 
condition  of  irritability — irritable  weakness — and  inability  to  con- 
centrate the  attention  for  any  length  of  time.  This  attention  dis  - 
order  is  often  responsible  for  what  appear  to  be  amnesias.  As  a 
matter  of  fact  little  or  no  attention  was  paid  to  the  event  sup- 
posed to  have  been  forgotten  so  that  it  never  was  adequately 
impressed  in  the  first  case. 

The  mood  is  pessimistic,  often  hypochondriacal.  The  simple 
depression  that  goes  with  this  state  is  often  of  the  nature  of  a 
symptomatic  depression.  The  hypochondriacal  ideas  referable 
to  the  particular  viscera  are  to  no  small  extent  fostered  by  the 
treatment,  in  many  cases,  which  centers  the  patient's  attention 
upon  his  various  bodily  functions. 

To  the  condition  of  those  patients  who  pay  marked  and  more  or 
less  continuous  attention  to  the  functions  of  their  bodily  organs 
the  name  hypochondria  is  given. 

Causes. — ^The  cause  of  neurasthenia  is  usually  put  down  as 
overstrain,  mental  or  physical.  The  so-called  strenuous  life  of 
the  present  day  is  believed  to  be  responsible  for  many  cases.  The 
strenuous  life,  however,  has  offered  material  for  criticism  for 

2.S5 


256  OUTLINES   OF   PSYCHIATRY. 

hundreds  of  years,  Cicero  wrote  against  it  in  the  old  Roman 
days.  What,  to  my  mind  is  more  characteristic  of  the  times,  not 
in  opposition  to  all  other  times,  but  in  distinction  from  the  period 
of  the  immediate  past  is  idleness,  especially  of  the  women.  The 
women  of  the  well-to-do  classes  have  literally  nothing  to  do. 
Immense  corporations  make  and  provide,  not  only  all  the  neces- 
sities but  all  the  luxuries.  Servants  do  all  the  manual  work  and 
there  is  nothing  left  for  her.  She  is  therefore  constrained  to 
lead  a  life  of  comparative  uselessness  and  idleness.  It  is  a  life, 
however,  that  does  not  satisfy.  In  addition  to  its  uselessness  it 
becomes  a  life  of  longing  for  something  usually  indefinable,  a 
life  of  shattered  hopes,  of  ambitious  longings  that  don't  come  true, 
of  unfulfillment.  Having  no  outer  interests  the  thoughts  nat- 
urally turn  to  self  and  in  this  factor  is  laid  the  foundation  of  the 
hypochondria  that  these  patients  suffer  from,  the  eternal  com- 
plaining of  little  nothings.  Having  lost  their  touch  with  reality 
and  become  self-centered  their  own  ego  occupies  a  too  prominent 
place  in  their  perspective.  Their  world  is  a  world  in  which  they 
occupy  the  central  point,  everything  has  some  relation  to  them, 
they  become  suspicious,  carping  critics,  gossips  and  scandal  mon- 
gers. To  try  and  escape  from  this  inner  sufifering  they  often 
engage  in  a  delirious  round  of  social  functions  and  break  down 
apparently  from  overexertion  in  keeping  up  their  social  duties. 
This  is,  however,  only  the  obvious  cause ;  the  real  cause  lies  much 
deeper.  Being  somewhat  physically  tried,  having  failed,  having 
no  real  interest,  she  is  indifferent  to  all  except  her  personal  suf- 
ferings. Exertion  is  only  exertion  and  serves  no  special  end,  fits 
in  nowhere  as  a  link  in  a  well-connected,  coherent  chain  of  events, 
so  they  end  by  being  unable  to  exert  themeslves  at  all.  Even 
getting  up  and  dressing  is  too  much ;  they  stay  in  bed. 

This  is  the  usual  picture  of  neurasthenia  which  of  course  may 
be  varied  in  innumerable  details.  The  important  thing  to  get 
from  the  illustration  is  the  importance  of  the  mental  factor  which 
may  be  described  as  an  introversion  to  the  auto-erotic  level. 

Diagnosis. — The  early  stages  of  paresis  and  arteriosclerosis  not 
infrequently  present  neurasthenic  symptoms.  An  examination  of 
the  physical  signs,  particularly  the  tendon  and  pupillary  reflexes, 
will  usually  clear  up  the  difficulty.  If  any  doubt  remains  an  ex- 
amination of  the  cerebrospinal  fluid  will  settle  it. 


BORDERLAND  AND  EPISODIC   STATES.  25/ 

The  prodromes  of  dementia  precox  may  be  extremely  difficult 
to  differentiate.  The  emotional  indifference  of  precox  is  in 
marked  contrast  to  the  emotional  state  of  neurasthenia. 

The  mild  depressions  of  manic-depressive  psychosis  may  re- 
semble neurasthenia.  A  demonstration  of  retardation  will  be 
about  the  only  way  to  differentiate  some  of  these  cases  except  by 
the  lapse  of  time  and  a  study  of  the  course. 

It  must  be  remembered  that  many  conditions,  both  mental  and 
physical,  may  have  neurasthenic  symptoms  associated.  This  is 
especially  important  to  recall  of  brain  tumor,  the  persistent  head- 
ache of  which  has  been  mistaken  for  a  neurasthenic  headache. 

Treatment. — In  the  main  the  treatment  should  be  tonic  and 
restorative.  The  Weir  Mitchell  rest  cure  is  effective  in  many  of 
these  cases  and  accomplishes  its  results  quite  as  much,  in  many 
cases,  because  of  the  effect  on  the  mind  of  the  patient  as  because 
of  the  result  in  improvement  of  bodily  health.  This  group  of 
cases  are  especially  favorable  for  a  rational  psychotherapy. 

In  the  class  of  cases  I  have  described  the  real  problem  is  to  get 
them  out  of  themselves  and  into  healthy  touch  with  the  world  of 
reality.  This  can  only  be  done  by  awakening  new  interests  and 
training  them  gradually  in  healthy  view-points,  and  a  continuity 
of  effort,  in  endeavoring  to  establish  the  habit  of  work.  The 
rational  approach  to  these  problems  is  via  the  psychoanalytic 
method.  This  is  an  easy  thing  to  say  but  one  of  the  most  diffi- 
cult of  therapeutic  problems. 

The  normal  individual  does  not  know,  from  his  sensations  at 
least,  that  he  has  a  heart,  a  stomach,  or  nerves.  A  form  of  treat- 
ment that  centers  the  patient's  attention  upon  his  bodily  functions 
may  therefore  do  harm.  It  is  a  commonplace  that  if  the  atten- 
tion is  directed  to  any  part  of  the  body,  sensations  will  soon  begin 
to  flow  from  that  part.  Very  carefully  devised  dietaries  carried 
out  with  great  precision  as  to  detail  may,  therefore,  do  much  to 
fix  the  patient's  hypochondriacal  ideas  with  reference  to  his  di- 
gestive organs.     Similarly  with  other  organs. 

Hysteria. — The  nature  of  hysterical  manifestations  has  been  a 
matter  for  discussion  and  theorizing  for  centuries.  About  the 
only  ground  upon  which  all  can  meet  to-day  is  that  the  manifesta- 
tions are  mental  in  origin  although  some  still  maintain  the  possi- 


258  OUTLINES   OF   PSYCHIATRY. 

bility  of  isolated  symptoms  not  susceptible  of  this  explanation. 
Babinski^  has  laid  down  the  dictum  that  no  symptom  can  be 
hysterical  which  cannot  be  produced  by  suggestion  and  removed 
by  persuasion.  To  the  condition  in  this  group  of  cases  in  which 
the  s>Tnptoms  are  capable  of  being  produced  by  suggestion  and 
removed  by  persuasion  Babinski  has  given  the  name  pithiatism. 

The  most  important  theories^  of  hysteria  are  those  of  Sollier^ 
who  regards  it  as  the  result  of  the  going  to  sleep  more  or  less 
locally  or  generally  of  the  cerebral  centers.  The  hysteric  is  a 
vigilambulist. 

Janet*  says  that  hysteria  is  "  a  form  of  mental  depression  char- 
acterized by  the  retraction  of  the  field  of  personal  consciousness 
and  by  the  tendency  to  the  dissociation  and  the  emancipation  of 
systems  of  ideas  and  of  functions  which  by  their  synthesis  consti- 
tute the  personality." 

His  theory  perhaps  comes  as  close  as  any  to  throwing  real  light 
on  the  situation.  From  the  standpoint  of  the  nature  of  hysteria 
his  theory  is  enlightening  as  tending  to  show  that  the  fundamental 
trouble  is  a  loose  organization,  a  faulty  synthesis  of  the  person- 
ality. Snyder^  and  Hellpach^  have  particularly  laid  stress  upon 
this.  Hysteria  is  a  disorder,  a  type  of  reaction  belonging  to  peo- 
ple who  in  mental  organization  are  still  children.  People  in  whom 
the  elements  that  go  to  make  up  the  personality  are  still  only 
loosely  bound  together,  they  are  in  the  adjustable  stage  of  de- 
velopment. 

The  most  important  theory  of  hysteria  to-day  is  that  of  Freud.'' 
He  regards  hysteria  as  due  to  the  operations  of  buried  sexual 
complexes.  The  symptoms  that  result  are  rue  to  the  conversion 
of  the  afifect  of  the  complex  into  physical  symptoms  (see  Chap. 
VH). 

1  Babinski:  My  Conception  of  Hysteria  and  Hypnotism,  Alienist  and 
Neurologist,  Vol.  XXIX,  Feb.,  1908. 

-White:  Mental  Mechanisms,  No.  8  of  this  series. 

^Sollier:  Hysterie  et  Sommeil,  Arch,  de  Neurol.,  Mai  et  Juin,  1907. 

*  Janet :  Les  Nevroses.     Paris,  1909. 

'  Snyder :  Definition  et  nature  de  I'hysterie,  L'Encephale  Aout,  1907. 

•"^  Hellpach  :  Cited  by  Jellifife:  Hysteria  and  the  Reeducation  Method  of 
Dubois,  N.  Y.  Med.  Jour.,  May  16,  1908. 

"  Freud :  Selected  Papers  on  Hysteria  and  other  Psychoneuroses,  Nerv. 
and  Ment.  Dis.  Monog.  Series  No.  4,  New  York,  1909. 


BORDERLAND   AND   EPISODIC   STATES.  259 

Conversion  is  the  essential  feature  of  the  symptomatology  of 
hysteria  according  to  Freud  while  the  essential  feature  of  his 
theory  of  the  origin  of  the  painful  complex  is  that  it  is  due  to  a 
psychic  conflict  of  a  sexual  nature,  a  conflict  between  desire  as 
represented  by  buried  complexes  and  attitudes  of  mind  the  results 
of  education.   . 

We  find,  therefore,  according  to  this  author  an  infantile  sexual 
complex  which  has  been  repressed.  In  certain  individuals  this 
repression  results  in  an  independent  activity  of  the  repressed  com- 
plexes. These  repressed  complexes  condition  erotic  fancies  which 
take  forms  incompatible  with  the  personality  and  are  in  turn  re- 
pressed. The  repressed  ideas  are  rendered  harmless,  greatly 
weakened,  by  the  transformtion  of  their  affective  excitement  into 
bodily  innervation — a  process  Freud  calls  "  conversion  "  while  the 
mental  symptoms  of  the  attack  represent  the  incursions  of  the 
erotic  day  dreams  to  the  surface.  Thus  in  Freud's  words :  "  Psy- 
choanalysis of  hysterical  individuals  shows  that  the  malady  is  the 
result  of  the  conflict  between  the  libido  and  the  sexual  repression, 
and  that  their  symptoms  have  the  value  of  a  compromise  between 
both  psychic  streams." 

The  mental  symptoms  of  hysteria  for  practical  purposes  have 
for  a  long  time  been  divided  into  those  constant  phenomena  which 
are  present  throughout  the  course  of  the  malady — the  symptoms 
of  the  inter  paroxysmal  period,  the  so-called  mental  stigmata,  and 
those  more  or  less  closely  connected  with  the  paroxysms — the 
episodic  phenomena. 

Mental  Stigmata. — The  principal  symptoms  of  the  interparox- 
ysmal  period  are:  Anesthesias — disseminated,  segmental,  hemi- 
anesthesia, hyperesthesias  usually  disseminated.  Motor  disturb- 
ances— contractions,  catalepsy,  paralysis.  Amnesias — partial  or 
general.  Delibity  of  the  emotions — loss  of  zvill  power,  sug- 
gestibility. 

It  must  be  fully  understood  that  all  these  symptoms,  even  the 
sensory  and  motor  disturbances,  are  purely  mental. 

Episodic  Phenomena. — ^These  phenomena  may  precede  or  fol- 
low an  hysterical  crisis,  or,  as  in  epilepsy,  may  be  substituted  for 
one.  They  are  principally  states  of  exaltation,  depression,  delu- 
sions, lethargy,  somnambulism,  fixed  ideas,  dilirium,  choreiform 
movements. 


26o  OUTLINES  OF  PSYCHIATRY. 

Conditions  of  delirium  with  great  confusion,  clouding  of  con- 
sciousness and  hallucinations  are  common. 

Dream  states  are  also  quite  characteristic  of  this  disease,  as 
they  are  of  epilepsy  and  alcoholism. 

A  characteristic  of  these  episodic  manifestations  is  their  very 
frequent  association  with  amnesia.* 

It  will  be  found  that  the  crises  of  hysteria  are  associated  with 
certain  unconscious  ideas,  that  are  connected  with  some  previous 
experience,  having  a  large  content  of  painful  emotion,  which  has 
been  forgotten. 

In  fact  the  psychology  of  hysteria  is  the  psychology  of  these 
unconscious  states  and  their  method  of  growth  by  a  process  of 
dissociation,  or  splitting  of  the  normal  consciousness.  Following 
these  periods  of  unconscious  activity  the  patient  may  have  abso- 
lutely no  recollection  of  what  has  occurred,  so  that  the  phenomena 
have  often  been  looked  upon  as  disturbances  of  memory. 

While  in  the  normal  individual,  however,  memories  lapse  by  a 
process  of  gradual  subsidence  in  the  face  of  the  intensive  present, 
in  these  other  conditions  the  events  cannot  be  said  to  lapse  in 
this  way  as  they  no  longer  are  in  direct  connection  with  the  per- 
sonal consciousness.  In  these  instances  a  dissociation  has  taken 
place,  there  has  been  a  fault,  a  line  of  cleavage  which  separates 
them  much  more  completely. 

This  cleavage  with  the  resulting  dissociation  is  an  abnormal 
phenomenon  and  the  manifestations  which  follow  result  from  a 
split-off  state  in  the  unconscious  which  tends  always  to  become 
dynamic. 

This  condition  of  dissociation  may  have  its  origin  in  a  severe 
emotional  shock,  or  be  the  reaction  of  a  badly  knit  personahty 
to  the  ordinary  demands  of  reality.  It  occurs  more  particularly 
in  young  people,  being  more  readily  brought  about  in  that  condi- 
tion of  lability  incident  to  development  and  as  at  this  time  the 
sexual  preempts  a  very  prominent  place  in  mental  life  the  result- 
ing picture  is  correspondingly  colored. 

The  dissociation  in  its  beginning  may  be  of  any  extent.  A 
certain  portion  of  the  then  consciousness  of  the  individual  at  the 
time  of  the  accident  is  separated  by  a  plane  of  cleavage  from  his 

8  Sidis  and  White :  Mental  Dissociation  in  Functional  Psychosis  in  Sidis : 
Psychopathological  Researches,  New  York,  1902. 


BORDERLAND   AND   EPISODIC   STATES.  26 1 

subsequent  mental  existence  and  in  relation  to  that  mental  exist- 
ence is  said  to  be  unconscious. 

The  process  of  dissociation,  having  once  begun,  tends  to  con- 
tinue and  new  material  is  constantly  being  added  to  this  secondary 
state  by  further  cleavage  and  also  by  assimilation  by  this  state 
itself  as  it  begins  to  lead  an  independent  existence.  Thus  the 
tendency  is  for  it  to  continually  grow,  and  when  that  growth 
takes  place  by  repeated  cleavage,  to  grow  at  the  expense  of  the 
personal  consciousness. 

This  is  the  process  of  dissociation  but  associated  with  it  is  the 
dynamogenic  quality  of  the  dissociated  states  spoken  of  above 
and  which  is  responsible  largely  for  the  manifestations  that  have 
attracted  attention.     How  can  this  factor  be  explained? 

In  the  normally  functioning  mind  there  is  constantly  going  on 
a  "battle  of  motives,"  a  struggle  for  supremacy  between  the  sev- 
eral elements,  much  like  the  struggle  recently  described  as  between 
the  physical  elements  of  the  body  which  results  in  certain  struc- 
tural types.  The  result  of  this  is  that  differences  of  tension  tend 
to  occur  in  different  areas,  but  as  these  areas  are  all  organically 
connected,  discharge  taking  place  along  the  lines  of  least  resist- 
ance drains  those  at  high  tension.  Inhibition  by  drainage  (Mc- 
DouGALL^)  occurs. 

Now  in  these  dissociated  states,  separated  from  the  personal 
consciousness  by  a  plane  of  cleavage  a  plus  tension  finds  no  relief. 
The  energy  not  being  drained  as  normally,  accumulates  to  the 
point  of  explosion,  and  breaking  over  the  gap  which  separates  it 
from  the  upper  strata  manifests  itself  in  waves  of  disturbance 
therein.  Thus  we  have  the  phenomena  of  epileptiform  and  hys- 
teriform  crises,  transient  deliria,  episodic  depressions  and  a  multi- 
tude of  other  sensori-motor  expressions.  These  expressions  recur 
and  naturally  tend  to  become  periodic. 

On  the  other  hand,  during  periods  of  inactivity  of  the  upper 
consciousness,  as  in  hypnotic,  hypnoidal  (Sidis^")  and  dream 
states,  the  secondary  states  tend  to  assume  the  ascendancy. 

8  McDougall :  The  Nature  of  Inhibitory  Processes  within  the  Nervous 
System,  Brain,  1903. 

1°  Sidis :  Psychopathological  Researches,  New  York,  1902.  An  Experi- 
mental Study  of  Sleep,  Jour.  Ab.  Psych.,  Vol.  Ill,  Nos.  i,  2  and  3,  1908. 
Studies  in  Psychopathology,  Boston  Med.  and  Surg.  Jour.,  Vol.  CLVI, 
Nos.  II,  12,  13,  14,  and  15,  1907. 


262  OUTLINES   OF  PSYCHIATRY. 

Whether  the  secondary  states  ever  assume  the  dignity  of  a  per- 
sonality or  not  is  merely  a  question  of  degree.  They  tend  to 
organize  and  to  grow  and  if  the  process  keeps  up  it  is  only  a 
question  of  time  when  a  new  personality  will  be  born.  If  these 
states  grow  largely  at  the  expense  of  the  personal  consciousness 
this  latter  may  finally  assume  a  relative  position  of  inferiority. 

Hysterical  Psychoses. — Hysterical  delirium,  stupor,  and  dream 
states  especially  may  be,  and  usually  are,  only  transitory  disturb- 
ances but  they  may  be  of  considerable  duration  and  in  any  case, 
while  they  last,  are  veritable  psychoses. 

Aside  from  these  acute  episodes  there  are  a  few  cases  that 
throughout  a  prolonged  attack  seem  to  present  only  hysterical 
symptoms.  There  are  other  cases  while  presenting  predominantly 
hysterical  symptoms  present  also  other  symptoms  which  ally  them 
to  some  other  psychosis. 

Just  where  these  cases  belong  is  doubtful.  We  must,  however, 
concede  the  possibility  of  hysterical  symptoms  developing  in  con- 
nection with  almost  any  other  psychosis.  A  certain  few  cases 
start  as  apparently  purely  physical  and  after  a  more  or  less  pro- 
longed course  deteriorate,  the  degenerative  hysteria,  of  the  older 
writers. 

The  trouble  is  that  we  have  not  as  yet  been  able  to  define  with 
sufficient  accuracy  the  limits  of  hysteria. 

Diagnosis. — Epilipsy  is  the  most  difficult  disease  from  which 
to  differentiate  hysteria.  This  is  particularly  so  because  of  the 
convulsive  attacks  in  each.  The  diagnosis  must  often  rest  upon 
the  presence  of  the  hysterical  stigmata  in  the  interparoxysmal 
period,  as  the  attacks  are  often  not  seen  and  cannot  be  distin- 
guished by  the  description  given.  The  presence  of  these  stigmata 
will  usually  suffice,  as  hysterical  convulsions  and  true  epileptic 
convulsions  seldom  occur  in  the  same  patient.  Hystero-epilepsy 
is  not  a  combination  of  the  two  diseases,  but  hysteria  with  asso- 
ciated epileptiform  attacks. 

The  amnesia  of  hysteria  is  peculiar  in  that  careful  questioning 
will  disclose  islands  of  memory  throughout  the  amnesic  region. 
These  islands  will  often  not  be  the  same  on  repeatedly  going  over 
the  ground.     The  field  of  memory  fluctuates. 

The  differentiation  from  the  other  psychoses  is  to  be  made 
from  the  history  and  the  presence  of  hysterical  stigmata. 


BORDERLAND   AND   EPISODIC   STATES.  263 

The  whole  question  of  the  relation  of  hysteria  to  other  diseases, 
to  mental  diseases  such  as  dementia  precox,  to  neuroses  such  as 
epilepsy,  to  multiple  sclerosis,  chorea,  etc.,  has  been  admirably 
and  sanely  reviewed  by  Voss^^  in  his  recent  work. 

If,  as  seems  to  be  generally  acknowledged,  the  hysterical  An- 
lage,  the  tendency  to  hysteria,  or  hysterisability  as  Bernheim 
would  have  it,  may  remain  indefinitely  latent  until  something 
happens  to  produce  the  characteristic  response,  then  I  do  not  see 
why  the  so-called  hysteriform  accompaniments  of  these  various 
diseases  cannot  properly  be  considered  as  true  hysteria.  Why 
should  not  a  multiple  sclerosis  be  the  activating  agent  in  breaking 
down  the  resistance  to  the  outcrop  of  the  hysterical  reaction  ? 

All  these  efforts  to  limit,  to  bind  in,  to  define  hysteria  within 
certain  prescribed  boundaries  are  not  at  all  convincing  and  they 
fail,  it  seems  to  me,  simply  because  hysteria  does  not  confine  its 
manifestations  to  any  definite  limits.  It  spreads  out  into  all  the 
available  and  adjoining  territory  and  is  indefinite  and  hazy  in 
its  outlines  quite  like  other  natural  phenomena.  We  must  not 
forget  that  definitions  are  human  devices — nature  has  few  sharply 
defined  boundaries. 

The  effort  of  Babinski  to  exclude  all  phenomena  which  seem 
to  be  physical  in  character  seems  to  rest  on  entirely  inadequate 
conceptions.  The  whole  field  of  psychopathology  has  too  long 
been  dominated  by  that  bug-a-boo,  the  relation  of  the  mental  and 
the  physical  and  the  implied  necessity  of  conceiving  of  each  as 
in  essence  different  from  the  other.  This  is  but  another  example 
of  an  attempt  to  define  an  artificial  boundary  where  none  exists. 

As  between  the  most  definitely  physical  or  bodily  processes  on 
the  one  hand  and  the  highest  psychic  on  the  other,  an  infinity  ot 
gradations  exists  and  at  no  point  can  it  be  said  that  what  was 
one  has  become  the  other.  It  is  much  more  stimulating  and 
effective  to  stick  to  facts  wherever  they  may  lead  us  than  to 
create  arbitrary  boundaries  which  later  on  only  serve  to  cut  off 
our  entrance  to  certain  territories. 

It  seems  to  be  very  well  demonstrated  that  the  individual  reacts 
to  conditions  by  the  development  and  organization  of  mechanisms 
which  in  their  complex  manifestations  may  include  both  physical 
and  mental  components. 

^1  Voss :  Klinische  Beitrage  zur  Lehre  von  der  Hysteria.  Jena,  Gustav 
Fischer,  1909. 


264  OUTLINES   OF   PSYCHIATRY. 

It  seems  to  me  that  in  a  consideration  of  such  facts  we  may 
find  an  explanation  for  the  association  of  physiological  disturb- 
ances with  hysteria,  such  as  the  false  gastropathies  for  instance, 
and  also  an  explanation  of  those  cases  which  start  as  hysteria 
apparently  but  which  later  on  show  symptoms  of  permanent 
mental  deterioration.  Those  cases,  which  lead  to  a  change  of 
diagnosis  from  hysteria  to  dementia  precox,  also  lead  to  the  belief 
that  the  original  diagnosis  was  in  error.  Why  ?  Could  it  not  be 
possible  for  a  hysterical  type  of  reaction  in  a  badly  organized  in- 
dividual to  gradually  unloose  bits  of  physiological  mechanism 
until  organic  changes  had  wrought  permanent  damage? 

And  so  I  think  we  must  come  to  recognize  the  hysterical  type 
of  reaction  wherever  we  see  it,  whether  in  connection  with  other 
conditions  or  alone.  By  so  doing  we  will  have  a  broader  under- 
standing of  our  cases  than  by  always  insisting  upon  a  one-disease 
diagnosis. 

Treatment. — The  principle  of  treatment  is  to  reestabHsh  the 
broken  associations.  This  is  generally  best  accomplished  by  in- 
ducing a  semi-sleeping  state — ^the  hypnoidal  state  of  Sidis— ■ 
tapping  the  subconscious  in  this  way,  and  then  by  a  gradual 
arousing  of  the  patient  bridging  the  gap  between  it  and  the  upper 
consciousness. 

It  is  sufficient  to  effect  a  cure  of  the  special  manifestations,  in 
many  cases,  to  secure  a  full  recollection  by  the  patient  for  the 
events  forgotten  and  which  include  the  events  of  the  psychic  trau- 
matism. If  these  events  are  recalled  and  lived  through,  the 
patient  reacting  emotionally  fully  to  them  their  abnormal  effects 
will  disappear.  This  is  the  so-called  "cathartic"  method  of 
treatment.    The  more  recent  method  is  psychoanalysis. 

Psychasthenia. — Under  this  term  Janet^^  includes  obsessions, 
impulsions,  insanity  of  doubt,  tics,  agitations,  phobias,  delirium 
of  contact,  anguishes,  neurasthenias  and  the  bizarre  feelings  of 
strangeness  and  of  depersonalization  often  described  under  the 
name  of  cerebrocardiac  neuropathy  or  disease  of  Krishaber.  By 
considering  all  of  these  varied  conditions  together  as  results  of  a 
fundamental  underlying  state  he  would  thus  erect  psychasthenia 
into  a  psychoneurosis. 

This  psychoneurosis  represents  at  the  mental  end  of  the  scale 

12  Janet :  Les  Obsessions  et  la  psychasthenic.    Paris,  1903. 


BORDERLAND   AND  EPISODIC   STATES.  265 

the  conditions  which  at  the  physical  are  represented  in  neuras- 
thenia. In  fact  there  is  a  tendency  recently  manifested  to  con- 
sider only  two  great  psychoneuroses,  viz.,  hysteria  and  psychas- 
thenia.  This  psychoneurosis  has  as  its  fundamental  symptom  the 
lowering  of  the  psychological  tension.  If  we  can  think  of  our 
mental  force  in  mechanical  terms  and  conceive  of  it  as  flowing 
along  the  fiber  tracts  like  steam  in  a  pipe,  then  we  may  believe 
that  this  force  has  to  be  maintained  at  a  certain  tension  in  order 
that  the  perceptions  from  the  outside  world  may  be  appreciated 
at  their  true  value.  If  attention  is  lowered  the  perceptions  are  not 
acute.  This  lack  of  acuteness  gives  origin  to  feelings  on  the  part 
of  the  patient  of  incompleteness  and  insufficiency.  Now  this  state 
of  affairs  involves  a  certain  deficiency  in  the  perception  of  reality 
which  requires  a  certain  concentration  and  complexity  of  content, 
in  other  words,  a  high  psychological  tension. 

This  lowering  of  psychological  tension,  feelings  of  incomplete- 
ness and  deficiency  in  the  "function  of  the  real"  constitutes  the 
fundamental  feature  of  all  this  class  of  phenomena. 

To  use  another  illustration.  I  have  said  that  the  perception 
of  reality  required  a  high  psychological  tension.  It  is  as  if  the 
normal  response  to  reality  were  represented  by  the  explosion  of 
say  100  grains  of  gunpowder :  the  psychasthenic  response  would 
be  represented  by  70  grains.  In  other  words,  unless  the  tension 
is  high,  the  potential  up  to  a  certain  point,  the  resulting  explosion 
is  an  inadequate  reaction,  gives  but  a  faint  idea  of  what  it  really 
should  be. 

The  psychasthenic  symptoms  are  based  upon  this  inadequate 
perception  of  reality.  The  hazy  view  of  the  world  resulting  from 
the  lowered  psychological  tension  results  in  hazy,  inaccurate  ways 
of  thinking.  The  trends  toward  mysticism  in  art  and  literature 
are  results  in  point.  While  lack  of  efficient  perception  makes  the 
world  of  reality  seem  strange,  unknowable,  and  at  times  of  stress 
it  seems  to  the  psychasthenic  that  this  vast  external  world  of 
reality  would  close  in  upon  him  and  crush  him.  It  is  the  strange, 
the  not  understood,  the  mysterious  of  which  we  are  afraid  and  so 
are  accounted  for  the  states  of  fear  and  anguish. 

The  lowered  tension  gives  rise  to  various  symptoms  in  propor- 
tion to  the  degree  of  lowering.  If  the  mental  functions  are 
erected  into  a  hierarchy  in  proportion  to  the  difficulty  of  their 
18 


266  OUTLINES  OF  PSYCHIATRY. 

accomplishment,  it  will  be  seen  that  the  accurate  estimation  of 
reality  stands  first,  revery  and  imagination  come  lower  down,  and 
muscular  movements  last.  As  the  tension  is  lowered  reactions 
will  tend  to  follow  in  the  order  of  this  psychological  hierarchy. 

Psychasthenia  stands  midway  between  epilepsy  and  hysteria. 
In  both  psychasthenia  and  epilepsy  the  fundamental  condition 
Janet  thinks  is  this  lowering  of  psychological  tension.  In  epi- 
lepsy this  lowering  is  sudden,  very  profound,  leading  even  to 
unconsciousness,  and  is  then  practically  completely  recovered 
from,  while  in  psychasthenia  it  is  more  or  less  constant  but  of 
much  less  degree.  Thus  psychasthenia  is  attenuated  and  chronic 
epilepsy.  Hysteria,  on  the  other  hand,  is  characterized  by  a  "  re- 
traction of  the  field  of  consciousness."  While  in  psychasthenia 
the  defect  is  more  or  less  uniform  over  the  whole  field  of  con- 
sciousness, in  hysteria  the  portions  of  the  field  retained  may  be 
quite  up  to  normal  or  even  hypernormal. 

The  classification  of  the  various  symptoms  of  psychasthenia 
is  difficult  because  of  their  muliplicity  and  variability.  Using 
the  word  obsessions  in  a  broad  sense  to  include  the  conditions  I 
have  described  as  obsessions,  fixed  ideas  and  impulses,  in  the 
chapter  on  General  Symptomatology,  because  of  the  desirability 
of  considering  them  under  different  heads,  we  may  divide  obses- 
sions into  emotional,  intellectual  and  volitional,  in  accordance  with 
their  predominating  characters,  realizing  meantime  that  the  dis- 
tinctions are  only  general  ones  and  the  lines  of  differentiation  not 
hard  and  fast. 

Emotional  obsessions  include  the  various  phobias  and  the  morbid 
desires.  Some  of  the  more  common  phobias  are  agoraphobia, 
fear  of  open  places — the  subject  is  afraid  to  cross  an  open  square, 
hugs  to  railings  and  keeps  close  to  the  houses.  Claustrophobia, 
fear  of  closed  spaces,  crowded  rooms.  Astraphobia,  fear  of 
thunder  and  lightning.  Aerophobia,  fear  of  being  in  high  places, 
etc. 

These  phobias  come  on  suddenly,  overwhelm  the  patient,  who 
is  seized  with  trembHng,  pallor,  sweating  and  all  the  signs  of  fear, 
despite  the  fact  that  he  appreciates  fully  meantime  that  there  is 
no  reason  for  fear  but  has  a  full  understanding  of  the  morbid 
character  of  his  obsessions. 

The  morbid  desires  are  in  the  main  the  desires  for  liquor  and 


BORDERLAND   AND   EPISODIC   STATES.  26/ 

drugs.  In  dipsomania  the  patient  has  periodical  attacks  of  dis- 
comfort, often  with  a  feeling  of  pressure  on  the  head  and  tachy- 
cardia ;  this  continues  to  grow  worse  until  the  desire  to  take  liquor 
is  yielded  to.  We  have  somewhat  similar  conditions  with  desire 
for  morphine,  cocaine,  etc. 

Volitional  obsessions  include  the  various  manias.  Some  of  the 
more  common  manias  are  kleptomania — impulses  to  theft,  the 
patient  often  taking  what  is  not  wanted  and  what  he  could  afford 
to  buy.  Pyromania,  an  impulse  to  set  fire  to  things.  Arithmo- 
mania,  the  impulse  to  count  everything,  the  letters  in  a  word, 
objects  passed  in  the  street,  etc.  Onomatomania,  the  obsession 
of  a  word,  usually  the  impulse  to  repeat  it  over  and  over  again  or 
to  seek  for  it  in  one's  memory. 

These  manias,  as  in  dipsomania,  make  the  patient  uncomfortable 
until  yielded  to;  although  the  patient  appreciates  the  abnormal 
character  of  the  obsession,  the  tendency  has  finally  to  be  yielded  to. 
This  is  the  characteristic  described  by  the  german  word  Zwang. 

Intellectual  obsessions  are  the  obsessions  which  do  not  lead  to 
action  and  which  have  not  a  large  emotional  control.  Here  would 
be  included  the  doubters,  who  are  always  asking  themselves  ques- 
tions about  trivial  things,  though  often  in  regard  to  religious 
matters,  wondering  if  there  is  a  God  and  the  Hke.  The  so-called 
metaphysicians  especially  are  occupied  with  abstract  questions  on 
the  nature  of  the  universe,  problems  of  matter  and  mind  and 
the  like. 

Regis^^  makes  a  class  of  aboulic  obsessions  which  lead  to  inhi- 
bition of  all  action,  producing  such  symptoms  as  astasia-abasia — ■ 
inability  to  stand  and  walk.  This  symptom,  however,  is  usually 
hysterical. 

The  peculiarity  of  all  psychasthenic  symptoms  is  that  they  occur 
with  clear  consciousness,  the  patient  fully  recognizing  their  ab- 
normal nature.  The  new  psychoanalytic  movement  has  dismem- 
bered psychasthenia,  splitting  it  up  mainly  into  hysteria,  anxiety 
hysteria,  and  compulsion  neurosis. 

Course  and  Prognosis. — The  course  of  psychasthenia  is  episodic 
and  the  outlook  in  the  main  is  not  very  good  as  to  recovery,  as 
there  is  usually  a  pronounced  neuropathic  basis  for  the  symptoms. 

13  Regis :  A  Practical  Manual  of  Mental  Medicine,  1898. 


268  OUTLINES   OF   PSYCHIATRY. 

The  psychasthenic,  like  the  neurasthenic  state,  is  found  associated 
with  many  conditions  and  as  a  part  of  various  psychoses. 

Treatment. — The  treatment  should  be  directed  to  improving  the 
general  health,  but  the  main  line  of  treatment  is  mental  and  re- 
quires the  most  detailed  regulation  and  reeducation  of  the  mental 
life. 

A  rational  psychotherapy  is  indicated.  This  should  include  a 
careful  regulation  of  the  mental  life  within  the  powers  of  the 
individual,  a  getting  away  from  old  and  vicious  habits  of  thought 
by  being  shown  their  error,  but,  better,  by  being  directed  into 
new  channels.  The  treatment  involves  a  reeducation  and  is  quite 
as  delicate  and  skillful  a  matter  as  the  reeducation  of  the  mus- 
cular habits  in  ticquers.  It  is  no  field  for  the  novice,  much  less 
the  charlatan. 

Compulsion  Neurosis. — A  very  similar  mechanism  to  that  of 
hysteria,  according  to  Freud,  is  at  work  in  the  compulsion  neu- 
rosis. He  classifies  certain  of  the  phobias  and  the  obsessions 
(compulsions)  under  this  heading  instead  of  following  the  lead  of 
Janet  and  considering  them  as  symptoms  of  psychasthenia. 

In  this  class  of  cases  the  aflfect,  instead  of  being  converted  into 
physical  symptoms,  is  changed  over  by  displacement  to  some  indif- 
ferent idea.  The  disagreeable  idea  thus  remains  suppressed  but 
the  patient  cannot  understand  the  insistence  and  emotional  color- 
ing of  the  idea  to  which  the  affect  has  been  transferred. 

Freud^*  believes  the  complex  in  this  case  as  in  hysteria  has  its 
origin  in  the  sexual  life  and  says:  "The  obsession  represents  a 
compensation  or  substitute  for  the  unbearable  sexual  idea,  and 
takes  its  place  in  consciousness." 

The  fundamental  mechanism  in  compulsion  neurosis  seems  to 
be  an  alternation  between  love  and  hate  with  no  possibility  of  the 
formation  of  a  working  compromise. 

Anxiety  Neurosis  of  Freud.^° — Out  of  the  great  mass  of  mate- 
rial composing  the  psychoneuroses  and  which  otherwise  would 
be  classed  as  neurasthenia,  hysteria,  or  psychasthenia,  Freud  has 

1*  Freud :  Selected  Papers  on  Hysteria  and  Other  Psychoneuroses,  Nerv. 
and  Ment.  Dis.  Monogr.  Series,  No.  4.  Cited  by  Brill:  Freud's  Concep- 
tion of  the  Psychoneuroses,  N.  Y.  Med.  Record,  Dec.  25,  1909. 

if>  Freud :  Selected  Papers  on  Hysteria  and  Other  Psychoneuroses,  Nerv. 
and  Ment.  Dis.  Monogr.  Series,  No.  4. 


BORDERLAND  AND  EPISODIC  STATES.  269 

separated  out  certain  cases  which  he  thinks  have  a  definite  group- 
ing of  symptoms  and  so  are  entitled  to  consideration  as  a  noso- 
logical entity. 

The  symptoms  of  this  neurosis  are  in  the  main  a  general  irri- 
tability, anxious  expectation,  vertigo,  phobias,  and  parcesthesias. 
The  anxiety  aside  from  being  more  or  less  constant  in  the  form 
of  anxious  expectation,  or  apprehension,  comes  in  attacks  which 
are  of  various  forms,  the  principal  ones  of  which  are  cardiac  dis- 
turbances, respiratory  disturbances,  profuse  perspiration,  trem- 
bling and  shaking,  inordinate  appetite  often  with  dizziness,  diar- 
rhea, locomotor  dizziness,  congestions  (vasomotor  neurasthenia), 
parcesthesias. 

Unlike  hysteria  and  the  compulsion  neurosis  the  origin  of  the 
trouble  is  not  in  the  psychic  sphere  but  in  a  lack  of  harmonious 
adjustment  of  the  physiological  functions  of  the  sexual  organs. 
This  failure  of  physiological  adjustment  manifests  itself  in  the 
psychic  sphere  as  anxiety.  The  anxiety  not  having  a  mental 
origin  is  free  to  unite  with  any  idea.  There  comes  to  be  then 
"a  quantum  of  freely  floating  anxiety  which  controls  the  choice 
of  ideas  by  expectation  and  is  forever  ready  to  unite  itself  with 
any  suitable  ideation."^® 

Anxiety  Hysteria. — In  conversion  hysteria  the  repressed  affect 
is  drafted  into  bodily  innervations,  in  anxiety  hysteria  it  remains 
in  the  mental  sphere  producing  the  various  phobias.  This  is  one 
of  the  most  common  of  the  neuroses  and  the  most  frequent  to  be 
found  in  childhood.  It  is,  too,  perhaps  the  most  hopeful  for 
therapeutic  attack.     The  therapeutic  approach  is  psychoanalytic. 

Psychopathic  Constitution. — ^There  are  many  anomalies  of 
character  which  because  normal  or  usual  to  the  individual  cannot 
be  said  to  properly  constitute  a  psychosis,  but  because  they  lead 
to  a  rather  inefficient  type  of  adjustment  of  the  individual  to  his 
environment,  and  because  persons  exhibiting  these  peculiarities 
often  become  actively  disordered,  may  be  considered  as  border- 
land conditions. 

We  have  already  in  previous  chapters  learned  something  of 
the  hysteric  and  epileptic  characters.  We  know  the  general  type 
of  inefficiency  of  the  neurasthenic  and  latterly  have  described  the 

16  Freud :  Selected  Papers  on  Hysteria  and  Other  Psychoneuroses,  Nerv. 
and  Ment.  Dis.  Monogr.  Series,  No.  4. 


2/0  OUTLINES  OF   PSYCHIATRY. 

psychasthenic  character,  and  attention  has  been  called  to  the  unre- 
sistive  and  the  post-traumatic  types  with  the  intolerance  of  alcohol 
and  fever.  We  probably  also  have  a  manic-depressive  type  and 
lately  we  have  had  our  attention  directed  to  the  "shut-in"  type 
as  the  type  par  excellence  found  in  those  cases  which  develop 
dementia  precox. 

Besides  these  there  are  the  "cranks,"  who,  with  some  pet 
scheme,  closely  approach  the  paranoiac  type  and  that  host  of  ill- 
balanced,  eccentric  individuals  who  may  be  superficially  brilliant 
but  lack  continuity  of  purpose  and  capacity  for  the  continuous 
expenditure  of  effort  in  any  one  direction.  Their  life,  to  use  the 
well  chosen  words  of  Regis,^^  is  one  "  long  contradiction  between 
the  apparent  wealth  of  means  and  poverty  of  results." 

We  have  also  the  pathological  liar,  or  pseudologia  phantastica, 
and  certain  types  of  swindlers. 

Constitutiaonl  anomalies  of  mood  are  seen,  those  who  are 
always  depressed  for  no  particular  reason — psychopathic  depres- 
sion— and  the  opposite  state — psychopathic  exaltation.  Other 
cases  never  seem  to  be  quite  able  to  successfully  cope  with  con- 
ditions; they  are  the  failures  of  life,  the  cases  of  constitutional 
inferiority. 

Conditions  of  psychogenic  depression  occur  quite  often  in  psy- 
chopathic individuals.  Should  a  beautiful  young  woman  severely 
scald  her  face,  so  that  a  permanent  disfigurement  was  inevitable, 
a  considerable  depression  would  be  quite  natural.  Should  the 
depression  lead  to  suicidal  attempts  and  perhaps  delusions,  the 
psychopathic  basis  would  be  evident.  Many  weak  characters  who 
are  led  into  crime  develop  a  symptomatic  depression  when  caught 
and  sentenced.  More  pronounced  defects  of  character  are  seen 
in  the  criminal  classes,  many  of  whom  lack  the  ordinary  moral 
inhibitions  and  are  properly  moral  imbeciles. 

There  are  many  psychogenic  states  that  occur  in  psychopathic 
individuals — degenerates.  The  so-called  prison  psychoses^^  are 
types  and  come  about  as  the  patient's  reaction  to  the  difficulties 
in  which  he  finds  himself.  They  may  be  hysterical,  catatonic, 
paranoid,  according  to  the  type  of  individual.     They  clear  up 

1'^  Regis :  A  Practical  Manual  of  Mental  Medicine,  1898. 
18  Glueck :  A  Contribution  to  the  Study  of  Psychogenesis  in  the  Psycho- 
ses, Am.  Jour.  Insanity,  Jan.,  1912. 


BORDERLAND  AND  EPISODIC   STATES.  2/1 

promptly  when  the  stress  is  removed — ^pardon,  expiration  of  sen- 
tence, commutation  of  death  sentence,  etc. 

Simulation. — Simulation  has  generally,  and  rightly  meant,  a 
conscious  effort  to  deceive  by  imitating  the  symptoms  of  illness. 
Such  a  concept,  however,  is  not  adequate  either  for  diagnosis  or 
for  dealing  with  difficult  cases.  For  example,  it  has  generally 
been  supposed  that  if  a  patient  could  be  "  caught "  in  an  examina- 
tion by  some  trick  which  made  the  symptom  disappear  that  he 
was  therefore  a  simulator.  Thus  if  a  paraplegic  could  be  made 
to  get  up  and  run  under  the  stimulus  of  fear  the  conclusion  was 
that  he  was  a  simulator.  Our  knowledge  of  psychogenic  maladies 
in  general  and  of  hysteria  in  particular  has  changed  our  ideas 
about  such  matters.  We  know  that  the  paralysis  in  these  cases 
is  not  organic  but  functional  (psychological)  and  that  is  really 
all  that  the  above  experiment  demonstrates.  The  real  question 
in  such  a  situation  is  not  whether  the  paralysis  is  psychological, 
that  is  admitted,  but  whether  it  is  brought  about  by  causes  which 
are  unconscious  or  whether  there  is  on  the  part  of  the  patient  a 
clear,  conscious  intent  to  deceive  and  the  symptom  (paralysis)  is 
assumed  voluntarily  for  that  purpose.  In  the  former  case  the 
individual  is  obviously  sick,  in  the  latter  case  he  is  apparently  a 
malingerer. 

Even  assuming  though  that  we  are  dealing  with  a  malingerer  as 
defined  above  the  diagnosis  "  simulation "  is  not  an  adequate 
diagnosis.  It  merely  means  a  failure  of  capacity  for  dealing  with 
reality  at  a  relatively  high  level.  There  is  something  funda- 
mentally wrong  in  a  character  way  with  the  person  who  in  his 
dealing  with  reality  finds  it  necessary  to  resort  to  lies  and  deceit. 
If  this  is  borne  in  mind  the  treatment  can  be  much  better  adjusted 
to  the  needs  of  the  situation.  To  think  of  the  soldier,  for  in- 
stance, as  a  malingerer  pure  and  simple  means  that  he  will  be 
punished,  that  is  be  made  to  suffer  for  what  he  has  done.  To 
think  of  the  situation  as  one  of  defective  powers  of  adjustment 
will  mean  that  if  pain  is  inflicted  it  will  be  for  the  purpose  of  a 
definite  end,  improving  the  adjustment.  In  the  first  place  anger 
and  hate  are  the  motives  which  influence  the  character  and 
severity  of  the  punishment:  in  the  latter  case  the  character  and 
severity  of  the  punishment  are  chosen  to  effect  certain  ends, 
namely  increased  capacity  for  adjustment  to  reality,  the  better 


2/2  OUTLINES   OF   PSYCHIATRY. 

relating  of  the  two  interests,  the  interests  of  the  individual  and  tha 
interests  of  society.  Often  the  certainty  of  a  moderate  punish- 
ment will  prevent  the  outcrop  of  a  symptom,  when  the  individual 
is  strong  enough,  by  an  increased  effort  to  keep  himself  in  hand. 
Often  punishment,  no  matter  how  severe,  will  not  prevent  the 
symptoms.  In  the  first  place  the  individual  may  be  useful  ma- 
terial for  the  particular  service  required  (military),  in  the  second 
place  it  will  be  to  the  advantage  of  the  individual  not  to  be 
punished  (made  still  more  inefficient  by  the  severities  of  prison 
discipline  which  he  is  ill-conditioned  to  stand),  and  it  will  be  of 
advantage  to  society  (the  army)  not  to  waste  time,  effort  and 
money  in  trying  to  do  something  with  material  that  can  never 
measure  up  to  the  requirements. 

"  Shell-Shock." — Under  this  term  a  great  variety  of  conditions 
were  included,  more  particularly  during  the  early  part  of  the  war. 
Some  of  these  conditions  were  apparently  functional,  but  the 
finding  of  blood  in  the  cerebro-spinal  fluid  determined  their  or- 
ganic nature.  As  the  matter  stands  now  the  "  shell-shock  "  cases 
include  varieties  of  the  psychoneuroses,  particularly  conversion 
hysteria  and  anxiety  hysteria.  Most,  if  not  all,  of  the  types  ot 
palsy  (monoplegias,  aphasias,  abnormal  attitudes  and  gaits)  the 
anesthesias  (blindness,  deafness)  belong  in  the  conversion 
hysteria  group.  Along  with  the  usual  psychoneurotic  symptoms 
may  go  unusually  marked  regressive  symptoms  (childishness, 
interest  in  toys)  which  have  often  been  fostered  by  the  forms  of 
treatment  originally  essayed. 

The  stresses  of  war  serve  to  bring  out  latent  neurotic  taints, 
to  cause  the  personality  to  break  down  along  lines  of  cleavage 
determined  by  the  inadequately  assimilated  complexes.  Treatment 
by  suggestion,  electric  shocks,  etc.,  can  only  be  symptomatic  and 
temporary  in  its  effects.  A  psychoanalytic  attack  affords  the 
rational  method  of  approach  and  if  time  does  not  permit  real 
analysis  at  least  the  methods  of  treatment  outlined  should  be 
fashioned  upon  the  principles  which  psychoanalysis  has  shown  to 
be  involved. 

Anomalies  of  the  Sexual  Instinct, 

Quantitative  Anomalies. — These  are  frigidity  or  lack  of  desire 
for  sexual  congress — sexual  ancesthesia — or  eroticism — sexual 
hystercesthesia. 


BORDERLAND  AND  EPISODIC   STATES.  2/3 

Qualitative  "Anomalies. — These  are  inversions  and  perversions. 
Inversion  consists  of  a  lack  of  harmony  between  the  physical  and 
the  psychical  sex  and  leads  to  homosexuality  or  desire  for  persons 
of  the  same  sex.  Various  physical  anomalies  are  often  found  in 
these  persons.  For  example,  the  general  conformation  of  the 
body,  pilosity,  etc.,  may  indicate  one  sex,  while  the  genitalia  are 
of  the  other. 

Sex  inheritance  is  alternative.  That  is  both  male  and  female 
characters  are  present  in  the  germ  and  only  one  normally  develops. 
Sometimes  there  seems  to  be  an  uncertainty  as  to  which  will 
develop  and  the  result  is  a  certain  mixture  which  may  take  place 
either  in  the  bodily  or  psychic  sphere  alone  or  in  both. 

The  perversions  are  many  and  include  the  various  abnormal 
means  of  gratifying  the  sexual  appetite. 

With  respect  both  to  inversion  and  perversion  we  must  remem- 
ber that  in  the  young  child  the  sexual  sense  has  not  developed 
and  later  as  it  develops  and  comes  into  prominence  it  differentiates 
and  tends  to  specialize  by  centering  its  aims  in  a  special  direction, 
i.  e.,  towards  the  opposite  sex  and  normal  coitus.  The  child 
before  this  takes  place,  is,  to  use  a  term  of  Freud's,  polymorph- 
ous-perverse. He  may  be  developed  in  any  direction  by  appro- 
priate influences  or  he  may  stay  in  the  undeveloped,  infantile 
stage. 

The  most  important  of  the  perversions  are : 

Masturbation. — Masturbation  is  very  frequent  among  psycho- 
paths and  very  often  a  result  rather  than  a  cause  of  mental  anoma- 
lies though  undoubtedly  an  important  factor  in  some  cases  of  acute 
psychosis.  A  transient  period  of  onanism  in  infancy  is  probably 
normal  and  serves  to  focalize  the  sexual  sensations  on  the  normal 
erogenous  zones.^' 

Active  Algolagnia  (Sadism). — The  gratification  of  the  sexual 
feeling  by  the  infliction  or  sight  of  pain — real  or  simulated — ^in  the 
latter  case  the  sadism  is  symbolic.  As  the  male  is  normally  the 
more  active  and  aggressive  in  the  sexual  relation  we  find,  as  might 
be  expected,  this  anomaly  more  frequently  in  men. 

Passive  Algolagnia  (Masochism). — The  gratification  of  the 
sexual  feeling  by  suffering  pain — real  or  simulated.     In  the  latter 

^9  Freud :  Three  Contributions  to  the  Theory  of  Sex,  No.  7  of  this  series. 


274  OUTLINES  OF  PSYCHIATRY. 

case  it  is  symbolic.  The  female,  being  the  more  passive  of  the 
two  sexes  in  the  sexual  relation,  so  we  find  an  exaggeration  of 
this  passivity  more  common  among  women. 

Homosexuality. — Sexual  desire  for  the  same  sex. 

Narcissism. — A  form  of  homosexuality  in  which  a  person  is 
desired  who  has  the  family  resemblance. 

Fetichism. — Sexual  excitement  and  gratification  by  the  sight, 
contact  or  possession  of  some  object  or  part  of  the  body.  The 
object  is  usually  some  wearing  apparel,  such  as  shoes,  handker- 
chief, petticoat  or  a  part  of  the  body  other  than  the  sexual  organs. 

Bestiality. — Sexual  relation  with  animals. 

Exhibitionism. — Sexual  gratification  by  exposing  the  genital 
organs. 

Necrophilia. — The  desire  to  have  sexual  congress  with  a  dead 
body. 


CHAPTER  XVIII. 

Idiocy  and  Imbecility. 

In  drawing  a  distinction  between  dementia  and  idiocy,  Esquirol 
well  said:  "The  demented  man  is  deprived  of  the  good  that  he 
formerly  enjoyed;  he  is  a  rich  man  become  poor;  the  idiot  has 
always  lived  in  misfortune  and  poverty."  The  idiot,  the  imbecile, 
the  feebleminded  lack  something;  the  insane  are  suffering  from 
a  disorder  of  that  which  they  possess. 

The  distinction  is  here  clearly  drawn  between  a  psychosis  and 
idiocy  and  imbecility.  The  former  is  a  breaking  down,  a  disorder 
of  mind,  the  other  is  the  result  of  a  certain  lack  of  mind.  In 
making  this  distinction  we  must  not  lose  sight  of  the  fact  that  the 
feebleminded,  imbecile  and  idiot  may  develop  a  psychosis,  and 
transient  attacks  of  mental  disturbance  of  this  sort  are  not  infre- 
quently observed  among  them. 

The  various  grades  of  idiocy  and  imbecility  may  take  their 
origin  at  any  point  in  the  development  of  the  individual,  during 
intrauterine  life,  at  birth  as  a  result  of  injury,  after  birth  as  a 
result  of  injury  or  disease  which  interferes  with  further  develop- 
ment. 

Thus  various  defect  conditions  fall  rather  naturally  into  certain 
groups,  but  the  same  difficulty  is  experienced  in  endeavoring  to 
classify  them  from  any  one  standpoint,  as  was  experienced  in  the 
realm  of  the  psychoses.  They  have  been  classified  under  the  fol- 
lowing heads. 

Feeblemindedness. — ^A  condition  of  slight  mental  defectiveness 
capable  of  much  improvement  by  educational  methods.  The 
afflicted  individual  may  ultimately  take  a  place  in  the  world  and 
be  self-supporting  under  favorable  circumstances. 

Imbecility. — A  condition  of  mental  deficiency  which  can,  how- 
ever, be  materially  improved  by  training,  but  not  sufficiently  for 
the  subject  to  take  a  place  in  the  world. 

Moral  Imbecility  is  a  condition  of  mental  defectiveness  which 
is  shown  predominantly  in  the  absence  of  the  highest  functions, 

275 


276  OUTLINES   OF   PSYCHIATRY. 

particularly  the  moral;  capable  of  training  to  a  considerable  de- 
gree, but  always  a  menace  to  society. 

Idio-Imhecility  is  a  condition  midway  between  idiocy  and  im- 
becility. 

Idiocy  is  a  condition  of  profound  mental  defectiveness.  The 
lower  grades  are  unteachable,  while  the  higher  may  be  trained 
slightly  in  self-help,  i.  e.,  to  attend  to  the  calls  of  nature. 

More  recently  a  definite  effort  has  been  made,  by  means  of  the 
Binet-Simon  measuring  scale  of  intelligence,  to  determine  the 
exact  psychological  age  of  the  child  as  distinguished  from  its 
chronological  age  (see  Chap.  XXI).  In  accordance  with  the 
results  attained  by  this  scale  the  American  Association  for  the 
Study  of  the  Feebleminded  have  defined  the  terms  idiot  and  im- 
becile anew.  An  idiot  possesses  a  degree  of  mentality  that  does 
not  go  beyond  the  normal  child  of  three  years,  an  imbecile  can 
not  go  beyond  seven  years,  and  from  seven  to  twelve  inclusive 
the  individual  is  known  as  a  moron. 

Cause. — The  causes  of  idiocy,  like  those  of  the  psychoses,  are 
numerous  and  varied.  Hereditary  defects  are  found  in  the  as- 
cendants in  a  large  proportion  of  cases.  Accidents  and  injuries, 
especially  those  associated  with  prolonged  labor  and  instrumental 
delivery,  are  common  causes,  while  diseases  involving  the  brain, 
such  as  the  acute  infections — pneumonia,  typhoid,  the  exanthe- 
mata— and  syphilis  often  play  a  role.  Alcoholism  in  one  or  both 
parents,  especially  drunkenness  at  the  time  of  conception,  may 
probably  be  a  very  important  factor,  while  any  infection,  includ- 
ing syphilis,  or  debilitating  conditions  of  the  parents  is  important. 
Fright  of  the  mother  probably  is  a  potent  factor  as  indicated  by 
the  statistics  of  births  during  sieges. 

The  popular  idea  that  consanguineous  marriages  are  productive 
of  idiocy  in  the  offspring  is  not  borne  out  by  statistics.  Con- 
sanguineous marriages  are  probably  no  more  dangerous  than  any 
others.  They  would  only  produce  unduly  direful  results  when  a 
bad  family  strain  is  present  in  both  parties  and  is  thus  cumulative 
in  the  offspring. 

General  Considerations. — The  symptoms  which  should  attract 
attention  to  the  mental  state  of  a  child,  aside  from  marked  physical 
abnormalities,  are  a  stupid  and  vacant  look,  prolonged  and  unpro- 
voked crying  and  difficulty  in  taking  the  breast. 


IDIOCY   AND   IMBECILITY.  2/7 

Later  on  it  is  noticeable  that  the  several  faculties  do  not  develop 
when  they  should.  The  child  neither  learns  to  walk  nor  to  talk 
as  early  as  other  children,  and  a  study  of  other  psychic  qualities 
would  develop  the  same  fact.  The  degree  of  defect  may  be 
measured  by  the  stage  of  development  reached  as  compared  with 
the  average  normal  child.  For  such  detailed  comparisons  the  stu- 
dent is  referred  to  special  works. 

The  idiot  is  usually  comparatively  quiet  or  very  exciteable  and 
has  been  correspondingly  classified  generally  as  apathetic  and 
excitable.  Certain  of  the  excitable  idiots  keep  up  certain  definite 
and  characteristic  movements  almost  continuously — these  are  the 
rhythmic  idiots.  Many  other  motor  anomalies  are  found  fre- 
quently, such  as  paralysis,  athetosis  and  epilepsy. 

The  well-recognized  clinical  types,  most  of  which  have  been 
known  for  many  years,  will  be  briefly  described  as  follows : 

Amaurotic  Family  Idiocy. — This  form  of  idiocy,  described  by 
Sachs,  seems  to  occur  almost  exclusively  among  Jewish  children. 
The  principal  symptoms  are  idiocy,  paralysis,  usually  spastic,  of 
all  four  extremities  and  progressive  blindness  from  optic  nerve 
atrophy.     The  patients  usually  die  during  infancy. 

Thyroigenous  Idiocy. — This  form  includes  idiocy  due  to  en- 
demic and  sporadic  cretinism  and  also  cases  due  to  myxedema. 
They  present  the  characteristic  symptoms  of  these  diseases  with 
those  of  idiocy. 

Hydrocephalic  Idiocy. — Idiocy  associated  with  hydrocephaly. 
Although  hydrocephalus  usually  leads  to  early  death,  life  may  be 
prolonged  to  an  advanced  age  and  marked  degrees  of  the  malady 
may  occur  without  the  profound  defects  of  idiocy.  A  case  of 
most  pronounced  hydrocephalus  recently  died  in  the  hospital 
upwards  of  fifty  years  of  age.  During  his  earlier  life  he  had 
made  a  livelihood  by  the  simple  process  of  ringing  a  church  bell. 
During  the  latter  month  of  his  life  he  deteriorated  very  pro- 
foundly, became  absolutely  blind  and  deaf,  unable  to  lift  his 
tremendous  head  from  the  pillow  and  died  in  coma.  All  of  the 
symptoms  were  undoubtedly  due  to  pressure,  as  the  brain  was 
found  post-mortem  to  be  little  else  than  a  bag  of  water. 

Microcephalic  Idiocy. — Idiocy  associated  with  extreme  small- 
ness  of  head.  No  definite  rule  can  of  course  be  laid  down  as  to 
the  definite  size  of  head  that  shall  be  considered  as  microcephalic, 


2/8  OUTLINES   OF   PSYCHIATRY. 

but  Ireland^  says  in  general  that  all  heads  below  seventeen  inches 
in  circumference  (431  millimeters)  may  be  so  considered. 

Paralytic  Idiocy. — Idiocy  associated  with  paralysis.  The  com- 
moner paralyses  are  the  monoplegias  and  diplegias.  These  con- 
ditions are  consequent  upon  gross  cerebral  lesions,  such  as  the 
lack  of  cerebral  substance,  resulting  in  a  cyst  connected  with  the 
ventricle — true  porencephalus,  or  due  to  cysts  not  connecting  with 
the  ventricles  and  resulting  from  softening,  hemorrhage  or  inflam- 
mation— false  porencephalus.  It  depends  entirely  upon  the  loca- 
tion of  the  lesions  as  to  the  symptoms. 

Epileptic  Idiocy. — Idiocy  with  epilepsy.  Epilepsy  is  a  com- 
mon associate  of  idiocy,  especially  in  those  cases  where  there  are 
gross  cerebral  lesions  as  in  the  paralytic  idiots.  The  term  epi- 
leptic idiocy  should  be  reserved  for  those  cases  where  the  idiocy 
may  reasonably  be  supposed  to  depend  on  the  epilepsy. 

Traumatic  Idiocy. — Idiocy  the  result  of  trauma.  The  most 
common  traumas  are  those  associated  with  prolonged  and  difficult 
labor  with  instrumental  delivery. 

Sensorial  Idiocy. — Idiocy  by  deprivation.  This  is  the  idiocy 
that  results  when  a  child  is  deprived  of  two  or  more  of  the  prin- 
cipal senses,  such  as  sight  and  hearing.  As  knowledge  and  edu- 
cation are  dependent  in  the  first  instance  upon  the  integrity  of 
the  sensorium,  such  a  serious  defect,  making  it  impossible  for  the 
child  to  receive  the  material  out  of  which  knowledge  is  elaborated, 
results  in  a  lack  of  development  of  the  mind. 

Inflammatory  Idiocy. — Here  we  find  idiocy  due  to  the  various 
forms  of  inflammatory  conditions  of  the  brain  and  meninges. 
The  cause  of  these  inflammations  may  be  any  of  the  infectious 
fevers,  as  pneumonia,  typhoid,  the  exanthemata.  The  inflam- 
mation may  be  meningitic  or  include  the  brain  proper,  as  in 
Strumpell's  infantile  encephalitis  of  the  motor  region  analogous 
to  anterior  poliomyelitis.  The  physical  symptoms  vary  according 
to  the  location  and  the  extent  of  destruction  of  tissue  resulting. 

Sclerotic  Idiocy. — Idiocy  found  not  infrequently  associated 
with  the  condition  known  as  tuberous  sclerosis.  These  cases 
usually  die  young,  being  greatly  reduced  by  frequent  epileptic 
attacks.     The  post-mortem  discloses  numerous  areas  of  firm  con- 

^  Ireland:  The  Mental  Afifections  of  Children.     Idiocy,  Imbecility,  and 
Insanity.    London,  1898. 


IDIOCY   AND  IMBECILITY.  279 

sistence  and  white  color  in  which  the  nervous  elements  are  lack- 
ing. These  patches  may  be  discrete  or  the  process  may  be  more 
general.  They  may  also  be  atrophic  or  hypertrophic.  A  hyper- 
trophic, diffused  process  produces  a  brain  very  much  larger  and 
heavier  than  normal. 

This  peculiar  pathological  condition  is  correlated  with  a  cuta- 
neous affection,  more  particularly  of  the  face  and  back — adenoma 
sebaceum — and  mixed  tumors  of  the  kidney  in  which  smooth  mus- 
cle fibre  is  most  prominent.  The  cerebellum  is  sometimes  in- 
volved, there  may  be  tumors  of  the  ventricles  and  rhabdomyoma 
of  the  heart.    Myomata  of  other  organs  have  also  been  observed. 

Syphilitic  T5^es. — Quite  a  large  percentage,  about  twenty,  of 
marked  conditions  of  defect  give  a  positive  Wassermann.  Aside 
from  those  patients  who  show  clinical  signs  of  hereditary  syphilis, 
Hutchinson  teeth,  linear  scars  about  the  corners  of  the  mouth  and 
the  nose,  and  interstitial  keratitis,  the  relation  of  the  syphilis  to 
the  defect  is  not  adequately  known.  Not  a  few  cases  of  juvenile 
paresis  are  mistaken  for  simple  forms  of  defect. 

Mongolism. — The  mongolian  or  kalmuc  type  is  so-called  be- 
cause of  the  resemblance  of  the  patient  to  the  mongolian  race.  It 
is  believed  to  be  congenital  but  not  hereditary  and  to  be  due  to 
the  exhaustion  of  the  reproductive  powers  of  the  mother. 

The  three  main  symptoms  refer  to  the  skull,  the  palpebral  fis- 
sures, and  the  tongue.  The  skull  is  brachycephalic,  diminished 
in  its  antero-posterior  diameter,  flattened  on  the  face  and  occiput 
but  without  recession  of  the  frontal  and  supraoccipital  regions  as 
in  the  microcephalic.  The  tongue  is  large,  the  circumvallate  papil- 
lae are  hypertrophied  and  there  are  marked  irregular  transverse 
fissures  probably  due  to  the  habit  of  sucking  the  tongue  and  the 
great  vulnerability  of  the  mucous  membranes.  The  hands  are 
broad,  clumsy  and  spatulate  and  there  is  a  frequent  incurving  of 
the  little  finger.  Their  general  health  is  poor  and  they  generally 
die  young.  They  are  usually  about  four  years  in  mental  develop- 
ment but  may  reach  seven.    Thyroid  does  no  good. 

Idiots-Savants. — These  are  rare  cases  who,  although  idiots, 
still  have  some  special  faculty  wonderfully  developed.  It  may  be 
music,  calculation,  memory  for  some  certain  variety  of  facts,  etc. 

The  calculators  can  name  the  answer  to  mathematical  problems 
almost  instantly;  the  musical  prodigies  often  play  well  and  even 
improvise;  one  of  my  cases  could  instantly  name  the  day  of  the 
week  for  any  date  for  years  back.  Many  of  these  cases  have  a 
capacity  for  mimicry  and  buffoonery,  and  from  this  class  undoubt- 
edly were  recruited,  in  the  old  days,  many  of  the  court  fools. 


280  OUTLINES   OF  PSYCHIATRY. 

The  psychology  of  these  cases  is  not  understood.  The  patients 
themselves  are  quite  unable  to  give  an  explanation  of  their 
abilities. 

Idiots  are  further  spoken  of  by  general  descriptive  terms  that 
indicate  their  resemblance  to  certain  types.  Thus  we  have  the 
Mongolian,  American  Indian  and  Negroid  types. 

A  considerable  deal  of  study  has  been  devoted  of  late  years 
to  all  sorts  of  defective  conditions.  Some  of  them  I  have  men- 
tioned elsewhere.  In  this  connection  I  will  call  attention  to  cer- 
tain developmental  conditions  in  which  the  body,  or  the  mind,  or 
both,  retain  the  child-like  type.  These  conditions  of  infantilism 
are  distinctly  higher  in  the  scale  than  the  various  types  discussed 
above,  Anton^  has  specially  studied  these  cases,  and  divides  in- 
fantilism into  general  and  partial.  Under  the  causes  of  general 
infantilism  he  lays  particular  stress  upon  the  balanced  relations 
of  the  ductless  glands.  In  the  cases  of  partial  infantilism  he  calls 
attention  to  the  cases  with  lack  of  development  of  the  sexual 
organs,  the  cardiovascular  system,  the  vocal  organs,  the  hair,  and 
finally  describes  a  form  of  pure  psychic  infantilism. 

Course  and  Prognosis. — The  condition  of  these  defectives 
usually  remains  stationary,  though  sometimes  severe  epilepsy  or 
severe  illness  may  reduce  them  still  further.  Some  may  actually 
develop  psychoses  with  hallucinations,  abnormal  activities,  and, 
if  the  mentality  permits,  delusions.  The  prognosis  is  absolutely 
bad  as  to  recovery  and  poor  even  as  to  life,  the  mortality  of  idiots 
being  far  above  that  of  the  general  population. 

Treatment. — Aside  from  the  thyroid  treatment  in  the  cretinous 
forms  the  main  treatment  is  educational.  This  can,  of  course, 
only  develop  what  is  already  there  and  in  the  main  should  be 
practical,  teaching  the  child  to  care  for  itself.  The  most  is  to  be 
hoped  for  in  the  sensory  types,  where  there  may  be  no  real  defect 
of  brain,  only  an  absence  of  sense  organs.  The  well-known  cases 
of  Laura  Bridgman  and  Helen  Keller  illustrate  the  wonderful 
resuks  that  may  be  accomplished  in  this  class  of  cases.  To  get 
results  at  all  requires  in  the  highest  degree  patience,  tireless  appli- 
cation and  ingenuity,  qualities  few  persons  possess. 

2  Anton :  Vier  Vortrage  tiber  Entwicklungsstorungen  beim  Kinde,  Ber- 
lin, 1908. 


PART  III 
METHODS  OF  EXAMINATION 


19 


CHAPTER  XIX. 

Principles  and  Methods  of  Examination. 

In  no  department  of  medicine  is  a  complete  examination  of  the 
patient  more  importanit  than  in  the  department  of  psychiatry. 
This  examination  must  not  only  include  the  symptoms  that  the 
patient  may  present  when  seen,  but  must  also  include  the  mosit 
detailed  obtainable  anamnesis.  It  must  be  borne  in  mind  that  a 
psychosis  is  a  condition  of  an  individual  who  was  previously  well 
and  that  above  all  it  is  not  a  something  that  comes  from  without, 
attacks  and  sizes  on  the  patient  like,  for  example,  a  pathogenic 
microorganism,  but  is  rather  to  be  considered  as  a  type  of  reaction 
of  the  individual  to  certain  inimical  conditions.  In  order,  there- 
fore, to  understand  a  particular  case  it  is  of  the  highest  importance 
to  have,  as  fully  as  possible,  a  conception  of  the  individual  before 
he  became  afflicted,  so  that  we  may  understand  the  symptoms 
which  are  the  expressions  of  this  reaction. 

The  scheme  of  examination  which  follows  is  directed  primarily 
to  elucidating  the  mental  state.  It  is  taken  for  granted  that  the 
student  is  familiar  with  the  various  methods  of  physical  exami- 
nation. The  omission  of  specific  directions  as  to  the  physical 
examination  is  not,  however,  to  be  taken  as  an  indication  that  it  is 
considered  unimportant.  On  the  contrary  a  physical  examination 
in  minute  detail  is  of  the  utmost  importance  and  unless  it  is  made 
the  risk  is  bound  to  be  run  that  the  key  to  the  whole  situation  will 
be  overlooked.  We  have  already  seen  (Chap.  Ill)  that  the  indi- 
vidual, from  the  standpoint  of  the  psychiatrist,  has  to  be  consid- 
ered as  a  biological  unit  and  that  mental  reactions  are  reactions 
of  the  unit  as  a  whole.  The  condition  of  the  several  organs  is 
therefore  of  great  importance  as  bearing  upon  the  ultimate  effi- 
ciency of  this  reaction. 

Mental  disorders  at  best  are  obscure  phenomena  and  no  pains 
should  be  spared  to  illuminate  them  from  every  quarter.  It  is 
not,  of  course,  expected  that  every  possible  physical  test  will  be 
applied  to  each  case.     For  example,  it  would  be  quite  foolish  to 

283 


284  OUTLINES   OF   PSYCHIATRY. 

Stain  for  the  malarial  parasite  unless  there  was  some  clinical 
evidence  of  malarial  infection.  The  usual  examination  of  heart, 
lungs  and  urine  should,  however,  be  made  in  each  instance.  Simi- 
larly with  the  neurological  examination :  Trousseau's  or  Chvostek's 
signs  would  hardly  be  thought  of  unless  tetany  were  suspected, 
while  in  every  case  the  reaction  of  the  pupils  to  light  and  accom- 
modation and  the  patellar  tendon  reflex  should  be  recorded  and  in 
patients  suspected  of  organic  brain  disease  or  paresis  the  Babinski 
reflex  and  Biernacki's  sign  would  be  examined  for. 

In  indicating  what  is  important  to  bring  out  in  the  examination, 
the  specific  character  of  the  information  desired  is  set  forth  for 
the  most  part  by  questions,  while  for  more  detailed  information 
special  tests,  which  are  given  in  full,  have  been  devised. 

The  complete  examination  will  be  considered  under  the  follow- 
ing five  headings,  the  first  three  of  which  relate  entirely  to  the 
anamesis  and  the  last  two  to  the  examination  of  the  patient 
himself. 

I.  History  of  the  Family. 
II.  History  of  the  Patient. 

III.  History  of  the  Present  Illness. 

IV.  General  Observation  of  the  Patient. 
V.  Special  Examination  of  the  Patient. 

A.  Physical. 

B.  Neurological. 
'General. 

C.  Mental.    -!  Special. 
Special  Tests. 

I.    History  of  Family. 
Parents: 

Were  parents  of  patient  related,  or  did  they  dififer  greatly  in 
age? 
Mental  Characteristics  of  Father  and  Mother: 

What  were  their  mental  characteristics  («".  e.,  disposition,  tem- 
perament, etc.)  ? 
Did  either  have  extraordinary  gifts,  one-sided  talents,  or  abnor- 
mal traits? 
Nervous  and  Mental  Disorders: 

Was  either  nervous?    What  were  the  symptoms? 


METHODS  OF   EXAMINATION.  285 

Did  either  have  convulsions? 

Did  either  have  periodical  headaches,  migraine  or  hemicrania? 

Was  either  neurasthenic? 

Was  either  ever  insane  ? 

Was  either  at  any  time  a  patient  in  a  hospital  for  nervous  or 
mental  diseases?  Where?  When,  and  how  long  did  he  or 
she  remain?  What  age  at  the  time?  How  long  after  or 
before  the  patient  was  bom? 

Did  either  have  any  other  disorders  (tics,  etc.)  ? 
Other  Diseases: 

Did  either  have  constitutional  diseases?     Syphilis?    Tubercu- 
losis ?    Diabetes  ?    Arthritis  ? 
'Alcohol: 

Was  either  addicted  to  the  use  of  alcohol  ?  How  much  did  they 
take  (in  day,  week,  month,  etc.)  ? 

How  long  was  it  taken  (years)  ? 

What  was  the  result  ?    Did  either  have  delirium  tremens  ? 
Crime  and  Suicide: 

Was  either  a  criminal  ?  What  crimes  did  either  commit  ?  Was 
he  or  she  punished  by  law?     What  was  the  punishment? 

Did  either  commit  or  attempt  suicide?    Under  what  circum- 
stances ? 
Defects  of  Siblings:'^ 

Did  the  siblings  of  either  father  or  mother  die  young?  What 
were  the  causes  of  death? 

Were  the  siblings  of  either  congenitally  deformed?  Were  any 
blind?    Deaf?    Dumb? 

Did  siblings  of  either  have  convulsions  or  other  nervous  disease  ? 

Were  any  insane,  or  patients  in  a  hospital  for  nervous  or  mental 
diseases? 
Grandparents: 

If  there  appears  to  be  a  hereditary  taint,  get  details  as  in  the 
above  questions  for  both  the  maternal  and  the  paternal  grand- 
parents. 
Siblings  of  Patient: 

Are  or  were  these  siblings  of  patient?  Give  in  order  (noting 
male  and  female),  and  get  age,  if  living,  or  age  at  and  cause 

*  Siblings  is  a  convenient  term  used  to   denote  children  of  the  same 
parent. 


286  OUTLINES  OF  PSYCHIATRY. 

of  death.  Inquire  regarding  nervous  and  mental  diseases  as 
in  questions  above. 
Objects. — An  understanding  of  the  psychosis  has  to  be  based 
upon  an  understanding  of  the  individual  in  whom  it  develops. 
To  this  end  it  is  necessary  to  gather  enough  information  about  his 
ancestors  to  appreciate  w^hat  he  came  into  the  world  with,  what 
were  the  hereditary  factors  with  which  he  started,  the  hereditary 
burdens,  maybe,  with  which  he  was  handicapped. 

A  study  of  the  immediate  family  will  also  give  some  idea  of 
the  character  of  environmental  influences  to  which  he  has  been 
subjected. 

II.    History  of  Patient. 

Full  Name  and  Age: 

(In  years  and  months.) 
Address: 

What  is  the  address  of  the  patient?     How  long  has  he  lived 
there  ? 
Occupation: 

What  is  the  business,  profession  or  occupation  of  the  patient? 
How  long  has  he  been  thus  occupied  ? 

What  previous  occupations  has  he  had  ?     Get  the  details  of  how 
long  he  has  retained  each  position,  how  successful  he  was  in 
each  one,  and  why  he  left. 
Birth: 

At  the  time  of  the  birth  of  the  patient  did  the  mother  have 
difficult   labor?     Were   instruments   used?     What   was    the 
cause  of  the  obstetrical  difficulty? 
Early  Childhood: 

Had  the  patient  convulsions  in  childhood?  How  old  was  he 
or  she  when  these  began?  How  many  years  did  they  con- 
tinue? How  long  was  each  seizure?  Give  details  regarding 
their  character  {e.  g.,  loss  of  consciousness;  local  or  general; 
how  brought  on;  etc.). 

Had  the  patient  rickets? 

What  other  diseases  in  childhood  did  the  patient  have  ?  When, 
and  with  what  result? 

When  did  he  learn  to  walk? 

When  did  he  learn  to  talk? 


METHODS  OF   EXAMINATION.  28/ 

School: 

When  did  he  first  attend  school?    Where  did  he  go?    How 
long  did  he  remain  at  school  ?     Why  did  he  leave  ?     In  school 
was  he  bright,  average,  or  stupid  ? 
Injuries  and  Disease  in  Later  Life: 

Has  the  patient  had  any  head  injuries  or  convulsions  (i.  e., 
beyond  what  was  mentioned  in  answer  to  question  above)  ? 

Has  he  had  gonorrhea  ? 

Has  he  had  syphilis  ? 

What  treatment  for  the  latter  did  he  receive,  and  what  were  the 
after  effects? 

What  other  diseases  has  patient  had?    What  were  the  after 
effects  ? 
Alcohol: 

Has  patient  taken  alcohol  in  any  form  (beer,  wine,  whiskey, 
tonic,  medicine,  etc.)  ?  How  much  of  each  has  he  taken, 
by  the  day,  week,  or  month?  How  long  has  he  been  taking 
alcohol?  Has  he  become  drunk?  Has  he  ever  had  delirium 
tremens.  Has  the  alcohol  made  him  pleasant  or  disagree- 
able? 
Other  Habits: 

Has  the  patient  taken  drugs,  such  as  cocaine,  morphine,  opium, 
or  any  others  for  long  periods  of  time? 

Has  he  used  tobacco?     Did  he  smoke,  chew  or  snuff?     How 
much  tobacco  did  he  use  in  a  day ;  in  a  week  ? 
Marriage  and  Children: 

Is  or  has  the  patient  been  married?  When  was  he  married? 
Is  the  (husband)  wife  still  living?  How  many  times  has  he 
been  married? 

Has  the  married  life  been  happy?     If  not,  why  not? 

Has  the  patient  or  wife  any  gynecological  or  menstrual  diffi- 
culties? When  did  catamenia  begin?  Has  it  been  regular? 
When  did  catamenia  end  ? 

Has  the  patient  or  wife  had  abortions  of  miscarriages?  Give 
the  details.  (How  often,  when,  and  how  were  they  brought 
about?) 

How  many  children  has  patient  had?  Give  them  in  order, 
noting  sex,  age,  nervous  and  mental  diseases,  etc. 


288  OUTLINES  OF  PSYCHIATRY. 

Previous  Attacks: 

Has  the  patient  had  similar  attacks  before?    What  were  the 
symptoms?     How  long  did  the  condition  last?    Did  he  go  to 
a  hospital  for  nervous  or  mental  diseases? 
If  he  has  not  had  similar  attacks  before,  inquire  if  he  has  had 
periods  of  depression  or  of  exaltation,  how  long  these  lasted, 
What  was  done  during  these  attacks,  etc. 
Get  any  further  details  about  the  disposition  of  the  patient ;  how 
he  got  on  with  his  companions,  whether  or  not  he  was  socia- 
ble, moody,  inclined  to  look  on  the  bright  or  the  dark  side  of 
things,  etc. 
Objects. — The  object  of  this  study  of  the  patient  is  to  acquire 
a  knowledge  of  his  makeup.     It  is  as  important  for  the  under- 
standing of  the  psychosis  to  know  the  type  of  personality^  out  of 
which  it  developed  as  to  know  the  hereditary  factors.     Here  we 
get  an  idea  of  his  ability  to  acquire  knowledge,  his  practical  capac- 
ity to  use  such  knowledge,  his  ability  to  fit  into  difficult  situa- 
tions— to  adapt  himself  to  his  environment.     This  power  of  adap- 
tation is  indicated  by  a  consecutive  statement  of  his  different  posi- 
tions, why  he  took  up  the  work  in  each  instance,  the  wages  he  re- 
ceived, whether  he  was  advanced  or  remained  a  long  time  in  an 
inferior  position,  how  long  he  was  employed  each  time  and  the  cir- 
cumstances surrounding  his  leaving.     Such  a  record  is  frequently 
illuminating  by  showing  lack  of  continuity,  inability  to  stick  to 
any  given  line  of  conduct,  and  incapacity  for  attaining  any  consid- 
erable degree  of  efficiency.     It  may  also  bring  out  the  character 
traits  upon  which  the  inefficiency  was  based,  as   for  example, 
passivity,  lack  of  initiative  and  creative  ability,  preference  for 
being  led,  and  uncertainty  and  impulsiveness.     Any  special  traits 
should  be  noted,  particularly  dominant  moods,  a  feeling  of  in- 
efficiency, excessive  optimism.     It  is  important  to  note,  too,  his 
capacity  for  coming  into  efficient  contact  with  his  fellows — Did 
he  make  friends  readily?     As  bearing  upon  these  character  traits 
the  sexual  life  should  be  inquired  into,  particularly  as  to  tenden- 
cies to  exclusiveness,  to  being  shut-in,  masturbation,  autoerotic 
phantasies  and  like  tendencies  which  interfere  with  an  efficient 
relation  to  reality. 

2  For  an  excellent  outline  for  the  study  of  make-up  see  "  A  Guide  to 
the  Descriptive  Study  of  the  Personality"  by  August  Hoch  and  George 
S.  Amsden,  N.  Y.  State  Hospitals  Bulletin,  Nov.  15,  1913. 


METHODS   OF   EXAMINATION.  289 

It  is  important  to  note  the  feeling  attitude  toward  the  several 
members  of  the  family  group,  particularly  the  father  and  mother, 
brothers  and  sisters  or  those  who  stand  in  their  place.  Recent 
psychological  studies  indicate  that  the  original  set  of  the  feelings 
as  determined  in  the  family  furnishes  the  form,  the  paradigm, 
into  which  future  emotional  experiences  must  fit.  It  is  not  un- 
common, for  example,  to  see  a  patient  reproduce  in  his  psychosis 
the  signs  of  illness  from  which  his  father  or  mother  or  some  mem- 
ber of  his  family  suffered  when  he  was  an  infant.  Such  matters 
are  of  great  importance  for  an  evaluation  of  the  patient's  emo- 
tional orientation. 

III.    History  of  the  Present  Illness. 

Cause  and  Onset: 

Did  the  present  illness  come  on  as  the  result  of  an  accident  or 
disease  ?  Did  the  patient  have  a  physical  or  a  mental  shock  ? 
Has  he  been  under  extraordinary  strain  for  some  time?  Is 
he  present  attack  thought  to  be  due  to  excess  of  any  sort? 
Specify. 

Did  the  attack  come  on  gradually  or  suddenly? 
General  Physical  and  Mental  Changes: 

Has  there  been  a  change  of  character  in  the  patient?  Has  he 
been  agreeable  to  his  wife  (husband)  and  children,  to  friends 
and  neighbors? 

Has  he  appeared  to  be  dazed,  or  quiet,  or  restless?  Has  he 
been  excited? 

Has  he  been  tidy  in  feeding  and  in  his  other  habits? 

Has  he  spoken  much  or  little,  or  has  he  been  dumb  ? 

Has  he  slept  well  ?  How  many  hours  has  he  slept  each  night  ? 
Has  he  slept  regularly? 

Has  he  eaten  well,  or  little  ?  Has  he  had  a  perverse  or  abnor- 
mal appetite?  Has  he  taken  his  meals  regularly?  Does  he 
give  any  explanation  for  his  poor  appetite  or  his  refusal  to 
eat? 

What  was  the  patient's  weight  before  the  illness  began? 

What  other  change  in  the  physical  condition  of  the  patient 
have  been  noted  since  the  beginning  of  the  illness  ?  Has  he 
been  tremulous  in  hands  or  in  speech?  Has  he  become  bald 
or  has  the  hair  whitened? 


290  OUTLINES  OF  PSYCHIATRY. 

Emotional  Condition: 

Has  the  patient  been  depressed,  or  unduly  joyful,  or  apathic? 
Has  he  been  passionate,  or  inclined  to  anger,  or  threatening? 
Hallucinations  and  Delusions: 

Has  he  heard  imaginary  voices?    What  have  they  said? 
Did  he  go  through  the  house  looking  under  the  beds  and  the 
furniture,  and  in  the  cupboards?    Did  he  listen  in  corners, 
or  at  the  walls  ?    Did  he  look  at  definite  points  for  some  time  ? 
Has  he  had  ideas  of  persecution,  or  of  grandeur? 
Do  the  delusions  change? 
Suicide  and  Homicide: 

Has  he  made  attempts  at  suicide;  at  homicide?    What  were 
the  exciting  causes  ? 
Intellectual  and  Memory  Defects: 

Has  he  shown  any  intellectual  defect?  Has  he  been  able  to 
carry  on  his  business  in  the  proper  manner?  Has  he  made 
peculiar  or  ill-advised  purchases? 
Has  he  shown  any  defect  in  memory  ?  Has  he  remembered  his 
business  engagements?  Does  he  recognize  his  friends  or 
relatives?  Does  he  mistake  persons?  Has  he  kept  track  of 
the  days  of  the  week  and  of  the  month?  Has  he  known 
where  he  has  been  ? 
Moral  and  Legal  Laxness: 

Has  the  patient  offended  against  the  law ;  against  morality  ? 
How  did  he  so  offend  and  with  what  result? 
Insight: 

Has  he  understood  that  he  has  been  mentally  different  than  he 
is  normally  ?    Does  he  appreciate  the  nature  of  his  disorder  ? 
Miscellanous: 

Has  the  patient  any  indications  of  stereotypy,  or  of  catalepsy, 

of  apparent  playfulness,  of  impulsive  actions? 
Add  any  other  information  that  the  informant  can  give  regard- 
ing mental  change  in  the  patient. 
Note  the  name  and  address  of  the  informant,  and  the  relation 

he  bears  to  the  patient. 

Object. — None  of  the  circumstances  surrounding  the  onset  of 

the  psychosis  are  unimportant.     They  should  all  be  considered 

to  have  meaning  and  their  meaning  should  be  sought  if  it  appears 

to  have  any  bearing  on  the  phychosis.     The  nature  of  the  hal- 


METHODS   OF   EXAMINATION.  29I 

lucinations  should  always  be  carefully  inquired  into.  What  the 
voices  say,  for  example,  is  bound  to  be  of  the  greatest  importance 
in  understanding  the  psychosis,  in  getting  some  idea  as  to  the 
nature  of  the  difficulties  at  the  psychological  level. 

IV.    General  Observation  of  the  Patient. 

Is  he  in  bed,  about  the  ward,  on  parole? 
Facial  Expression: 

Does  the  patient  look  sad,    fearful,   gay,  hostile,   suspicious, 
visionary,  expressionless,  intent,  arrogant,  sleepy,  cyanotic, 
demented  ? 
Movements: 
Are  there  movements  of  the  body,  of  the  head,  of  the  face?     Is 
there  Schnauzkrampf  ?    Are  there  rhythmic  quiverings  of 
the  mouth?     Are  there  wrinklings  of  the  forehead?     Are 
there  stereotyped  movements? 
Does  the  patient  walk  straight  and  to  some  purpose  ?     Does  he 
walk  irregularly  or  go  from  one  thing  to  another?    Does  he 
go  slowly  or  quickly? 
Appearance  and  Demeanor: 

How  does  he  carry  his  hands?    Is  his  hair  tidy  or  unkempt? 
Is  he  fully  dressed,  half-dressed,  or  naked?     Is  his  clothing 
well  kept?     Does  it  show  that  he  has  been  untidy  in  feeding 
and  in  drinking?    Do  the  clothes  fit  the  patient? 
Mental  Observations: 

Did  he  voluntarily  complain  of  ill-being,  or  ill-treatment,  or 

speak  of  his  delusions,  or  his  feelings? 
Was  he  coherent? 

Was  it  difficult  to  keep  him  on  the  line  of  questioning? 
Did  he  cooperate  in  the  mental  and  physical  examinations,  or 

did  he  raise  objections  to  them? 
How  did  he  receive  the  visits  of  the  physicians  ? 
Objects. — The  general  Object  of  this  examination  is  to  get  some 
information  that  the  patient  is  unable  to  tell  but  which  may  be  ob- 
tained by  being  able  to  understand  outward  manifestations.  All 
he  peculiar  facial  expressions,  attitudes  of  the  body,  emotional 
waves,  stray  expressions,  silly  conduct,  apparently  meaningless 
questions  have  significance  if  the  examiner  is  capable  of  finding 
it.  A  constant  attitude  of  watchfulness  for  meanings  is  the  key- 
note of  this  portion  of  the  examination. 


292  OUTLINES   OF   PSYCHIATRY. 

V.    Special  Examinations  of  the  Patient. 

A.  Physical  Examination. 

Status  Corporis. 

Form,  nutrition. 

Skin,  scars  (penis),  inside  of  mouth  (mucous 
patches,  scars  on  side  of  tongue  from  teeth,  ab- 
sence of  papillae), 

Decubitis. 

Bones  and  joints. 

Respiratory  system,  lungs. 

Circulatory  system,  heart,  oedema,  cyanosis  of  de- 
pendent parts. 

Genito-urinary  system,  urinalysis  (always). 

Gastro-intestinal  organs,  stomach  contents. 

Glands. 

Blood,  pressure,  haemoglobin,  erythrocytes,  leuco- 
cytes. 

Abdomen. 

B.  Neurological  Examination. 

Sensation. 

Touch : 

touch  threshold  on  the  head,  neck,  arms,  hands, 

legs,  feet,  abdomen,  chest, 
accuracy  of  localization  on  the  head,  neck,  arms, 

legs,  feet,  abdomen,  chest, 
double  point  threshold  on  the  head,  neck,  arms, 
hands,  legs,  feet,  abdomen,  chest. 
Pressure : 

discrimination. 
Pain: 

threshold  on  the  head,  neck,  arms,  hands,  legs, 
feet,  abdomen,  chest. 
Temperature : 

perception  of  temperature, 
perception  of  differences, 
Stereognostic  sense. 
Joint  and  muscle  sense: 
passive  movements. 


METHODS   OF   EXAMINATION.  293 

active  movements. 
Organic  sensations: 

hunger. 

thirst. 

fatigue. 

sexual. 

desire  for  urination. 

desire  for  defecation. 
Subjective  organic  sensations: 

formication. 

hyperesthesia. 

hyperalgesia. 

anesthesia. 

analgesia. 

feeling  of  reality. 
Movement: 

a.  rapidity  of  movement. 

b.  accuracy  of  movement. 

c.  force  of  movement. 

d.  limited  movements. 

e.  movements  of  special  parts. 

gait — spastic,  steppage,  ataxic,  cerebellar,  hemi- 
plegic,  propulsive. 

Cranial  Nerves. 
I.  Olfactory. 
Smell : 

tests  with  solutions. 

subjective  smells,  referred  to  self  or  en- 
vironment? 
II.  Optic. 

Vision : 

visual  acuity. 

visual  fields;  hemianopia,  contractions? 
color  vision, 
entoptic  phenomena, 
ophthalmoscopic  examination, 
hallucinations,  character? 
Ill,  IV,  VI.  Oculo-motor,  Patheticus,  Abducens. 

Movements  of  eyes  in  all  directions. 


294  OUTLINES   OF   PSYCHIATRY. 

Squint. 
Diplopia. 
Ptosis. 
Nystagmus : 

horizontal. 

vertical. 

rotary. 
Pupils : 

size. 

outline,  regular  or  irregular. 

reaction  to  light. 

reaction  to  accommodation. 

consensual  reflex. 

sympathetic  reflex. 
V.  Trigeminus. 

Corneal,  conjunctival,  palpebral  reflexes. 
Supraorbital,  infraorbital,  mental  points  of  exit 

sensitive  or  not. 
Chewing  movements. 
Taste : 

bitter,  sweet,  salt,  sour. 

subjective  tastes,  before  or  after  meals. 
VII.  Facial. 

Facial    symmetry — in    repose,    in    smiling,    in 

wrinkling  forehead,  in  showing  teeth. 
Naso-labial  folds,  are  both  equally  marked? 
Whistling,  puffing  cheeks. 
Movements  of  lips  in  showing  teeth  (tremor). 
Tremor  about  mouth  under  emotion  on  in  say- 
ing difficult  words  (test  phrases). 
Atrophy. 
Paralysis. 
VIII.  Acoustic. 

Hearing : 

acute,  subacute,  or  deaf? 

test  of  air  and  bone  conduction. 

high  and  low  tones. 

subjective  noises,  voices? 


METHODS  OF   EXAMINATION.  295 

Vertigo : 

subjective, 
objective. 
IX,  X,  XI.  Glossopharyngeal,  Vagus,  Accessory. 
Palate  at  rest,  in  phonation. 
Swallowing. 
Pharyngeal  reflex. 
XII.  Hypoglossal. 

Movements  of  tongue  on  protrusion   (hesita- 
tion— trombone  tongue) . 
Position  of  protruded  tongue. 
Tremor — fibrillary  or  en  masse? 
'A^trophy. 
Upper  Extremity. 
Atrophy. 
Hypertrophy. 

Muscular  spasm  or  hypotonia. 
Muscular  force — dynamometer. 
Tremor:  at  rest,  intention. 
F.  N.  T.  finger  nose  test. 
F.  F.  T.  finger  finger  test. 
Reflexes:  triceps,  radial  periosteal. 
Sense  of  position  of  joints. 
Stereognosis. 
Adiiadokokinesis. 
Sensitiveness  of  nerve  trunks. 
Trunk. 

Atrophy. 
Hypertrophy. 
Paresis. 
Dermographia. 

Reflexes :  cremasteric,  epigastric,  bladder,  anal. 
Tender  points:  verteibrse,  breast,  ovarian. 
Boisseau. 
Lower  Extremity. 
Atrophy. 
Hypertrophy. 

Muscular  spasm  or  hypotonia. 
Muscular  force. 


296  OUTLINES   OF  PSYCHIATRY. 

Reflexes:  patellar,  contralateral  adductor,  Adhilles 

tendon,  plantar. 
Babinski  toe  sign. 
Ankle  clonus. 
Nerve  trunk  sensitiveness. 
Lesegue. 
Romberg. 

K.  H.  T. :  knee  heel  test. 
Sense  of  pasition  of  joints. 
Gait — eyes  open  and  closed. 

C.  Mental  Examination  of  Patient. 
General  Memory  and  Orientation: 
What  is  your  full  name? 
Where  were  you  born?    Where  do  you  live? 
What  is  your  age? 
In  what  year  were  you  born  ? 
What  year  is  this?    What  month  is  this?     What 

day  of  the  month  ?    What  day  of  the  week  is  it  ? 
(If  the  answers  to  the  foregoing  questions  are  not 

consistent,  try  to  get  the  patient  to  explain  the 

discrepancy.) 
What  city  is  this?    What  place  is  this?    How  far 

from  your  home  is  this  ? 
When  did  you  come  here?    How  long  have  you 

been  here? 
Who  brought  you  here?    How  did  you  come? 
What  did  you  do  when  you  arrived? 
Whom  did  you  see  when  you  arrived?     Did  you 

ever  see  me  before  ?    What  is  my  name  ?    What 

is  his  (other  physician's)  name? 
When  did  you  get  up  this  morning?     Did  you  have 

breakfast?    What  did  you  have?     Did  you  have 

dinner?    Did  you  have  supper?    What  did  you 

have  for  those  meals? 
Has  anyone  visited  you?    Who  was  it?    Is  he  a 

relative?    When  did  he  come? 
General  Understanding  and  Insight: 

What  kind  of  a  place  is  this  ?    What  kinds  of  people 

are  here?    Who  are  they   (patients)? 


METHODS  OF  EXAMINATION.  29/ 

Who  are  they  (nurses  and  attendants)  ?  Who  am 
I,  or  who  are  we  (physicians)  ? 

Why  are  you  here?     Did  you  want  to  come? 

Is  there  anything  wrong  with  you?     Are  you  sick? 
Do  you  feel  quite  well?     Is  your  mind  all  right? 
Special  Memory: 

Family:  What  are  the  names  of  your  parents?  Are 
they  living?  Where  do  they  live?  What  was 
the  name  of  your  mother  before  she  was  married? 
How  many  brothers  and  sisters  did  you  have? 
Give  their  names?  Are  they  all  living?  Which 
ones  are  dead?  Of  what  did  they  die?  How  old 
were  they  at  time  of  death?.  Where  do  those 
living  live?    What  do  they  do? 

School:  Where  did  you  first  go  to  school?  What 
age  were  you  at  that  time?  What  other  schools 
did  you  attend?  Give  the  names  of  some  of  your 
teachers. 

Occupations:  What  is  your  occupation?  When  did 
you  first  go  to  work?  What  age  were  you? 
What  year  was  that  ?  What  other  work  have  you 
done  ?  Give  the  dates  and  the  time  for  each  posi- 
tion that  you  have  had,  and  tell  why  you  left  each 
place  ? 

Marriage  and  Children:  Are  you  married?  When 
were  you  married?  How  long  ago  is  that? 
What  was  your  wife's  (or  your)  maiden  name? 
Have  you  children?  When  were  they  born? 
How  many  are  now  living?  How  old  are  those 
now  living?  What  are  their  names?  Where  do 
they  live  ?  How  many  are  dead  ?  How  old  were 
those  that  died?  Of  what  diseases  did  they  die? 
Has  your  wife  (or  you)  had  miscarriages  or 
abortions  ? 

Diseases:  What  diseases  did  you  have  as  a  child? 
Did  you  ever  have  convulsions  ?  In  these  did  you 
lose  consciousness?  Did  you  ever  have  a  blow 
on  the  head  or  a  fall?  Have  you  had  syphilis? 
Were  you  treated  for  this?     How  long  ago  did 


298  OUTLINES   OF   PSYCHIATRY. 

you  have  it  and  how  lond  did  the  treatment  con- 
tinue? Did  your  hair  fall  out?  Did  you  have 
sores  on  your  penis  (or  vulva)  and  other  parts 
of  the  body?  Other  details  of  the  effects  of  the 
syphilis. 

Alcohol:  Do  you  take  alcohol  in  any  form?  How 
much  do  you  take  (number  of  glasses  a  day  or 
week)  ?  Have  you  ever  been  drunk?  Have  you 
ever  had  delirium  tremens  ? 

Other  Drugs:  Have  you  ever  taken  cocaine  or  mor- 
phine?    How  long  have  you  taken  them?     How 
much  have  you  taken  in  a  day? 
Special  Examination  About  the  Present  Condition: 
Special  Insight  Into  the  Condition  : 

Emotional:  Do  you  feel  all  right,  or  depressed,  or 
excited,  or  indifferent?  Are  you  always  this 
way?  If  not,  how  are  you  at  other  times  ?  How 
were  you  six  months  ago?  When  did  this  feel- 
ing begin?  What  was  the  cause  of  it?  Did  it 
come  on  suddenly?     Are  you  sad  or  afraid? 

a.  Have  you  had  any  peculiar  experiences? 

b.  Is  anything  being  done  to  you  or  has  anything 

been  done  to  you  to  make  you  sad  or  afraid? 

c.  If  not,  why  are  you  sad  or  afraid? 

d.  What  do  you  fear  ? 

c.  Do  you  think  you  are  being  watched,  or  talked 
about  ? 

/.  Have  people  been  persecuting  you,  or  have  they 
tried  to  poison  you,  or  to  rob  you,  or  to  influ- 
ence your  mind,  or  to  compel  you  to  do  things 
that  you  do  not  wish  to  do? 

g.  Who  are  trying  to  do  these  things  ? 

h.  Why  do  they  do  it? 

i.  How  have  your  companions  and  your  friends 
treated  you?  How  has  your  wife  (or  hus- 
band) treated  you? 

j.  Has  this  been  planned  out? 

k.  What  makes  you  think  so?  (Get  a  full  ac- 
count of  the  systematization  of  the  delusions 


METHODS   OF   EXAMINATION.  299 

not  note  especially  the  retrospective  interpre- 
tations and  the  falsifications  of  the  same.) 

Bodily:  Is  your  bodily  condition  good  ?  Do  you  feel 
physically  well  ?  (Get  a  voluntary  account  of  any 
peculiar  bodily  feeling  of  the  patient,  and  if  this 
is  not  possible  carefully  question,  using  as  few 
leading  questions  as  possible,  to  bring  out  any 
localized  or  general  feeling  of  bodily  change,  etc.) 

Head:  Does  your  head  feel  all  right?  How  is  your 
mind?  (If  there  is  insight  into  the  condition,  get 
a  full  account  from  the  patient  of  what  he  thinks 
regarding  the  changed  conditions.) 

a.  Do  you  have  peculiar  thoughts? 

b.  Do  thoughts  to  do  or  say  things  spring  up  in 

your  mind? 
A  uditory  Hallucinations: 

a.  Do  you  hear  things  ? 

b.  Are  they  noises? 

c.  When  do  you  usually  hear  them?    Are  they 

heard  oftener  when  you  are  alone,  or  with 
other  people? 

d.  Where  do  they  come  from?     From  the  people 

about  you,  or  from  the  walls  and  ceilings,  or 
from  other  rooms? 

e.  If  voices,  can  you  recognize  them?    Are  they 

plain  ?  Are  they  real  voices  or  only  thoughts  ? 
Do  you  hold  conversations  with  them?  Do 
you  reply  to  their  questions  or  to  what  they 
say?  Do  you  reply  aloud,  or  do  you  onty 
think  the  reply?  Do  you  say  pleasant  o\ 
disagreeable  things?  Do  the  voices  or  noises 
go  on  continually  ?  Do  they  stop  when  other 
people  talk  with  you,  or  when  you  talk,  or 
when  you  listen  to  other  things,  for  example, 
music  ? 
Visual  Hallucinations: 

a.  Do  you  see  things?     Are  they  people,  or  ani- 

mals, or  things? 

b.  When  do  you  usually  see  them,  in  daylight,  in 


300  OUTLINES   OF   PSYCHIATRY, 

the  dark,  when  you  are  in  bed,  when  your 
eyes  are  open  or  shut? 

c.  Do  they  move  or  remain  in  one  place?    Do 

they  seem  to  be  in  special  places  on  the  floor, 
in  the  corners  of  the  room  ? 

d.  Do  they  always  seem  to  be  in  front  of  your 

eyes?    Can  you  get  rid  of  them  by  turning 
your  head? 

e.  Do  they  seem  natural?    Are  they  the  colors 

you  would  except  such  things  to  have?    Are 
they  transparent,  so  that  you  can  look  through 
them? 
/.  Can  you  get  them  to  disappear?    How  do  you 
do  this? 

Memory:  Is  your  memory  good?  Has  it  always 
been  good  (or  poor)  as  it  is  now?  Have  you 
difficulty  in  remembering  any  special  things? 

Attention:  Can  you  attend  to  things  as  well  now  as 
you  could? 

Thinking:  Can  you  think  well?  Do  you  understand 
readily  what  is  said  to  you?  Does  it  take  you 
some  time  to  think  out  the  answer  to  questions? 
Do  you  understand  what  you  read  ? 

Capability:  Can  you  do  things  as  well  now  as  you 
could?  Do  you  have  any  difficulty  in  fixing  your 
mind  on  a  thing?  Have  you  any  difficulty  in 
starting  to  do  things?  Do  you  feel  more  disin- 
clined to  get  up  in  the  morning  than  you  used  to  ? 
Have  you  any  difficulty  in  dressing,  in  eating,  in 
speaking,  in  walking?  Do  you  feel  able  to  go  to 
work? 

Sleep:  Do  you  sleep  well?  How  many  hours  at 
night?  Do  you  ever  sleep  in  the  daytime?  Do 
you  feel  rested  after  your  sleep? 

Dreams:  Do  you  dream?    How  often  do  you  dream? 

a.  Do  you  dream  of  things  that  have  happened  to 

you  recently,  or  some  time  ago? 

b.  Do  you  dream  of  seeing  things,  or  of  hearing 

things,  or  of  things  tasted,  smelled,  touched, 
etc.? 


METHODS  OF  EXAMINATION.  3OI 

c.  Do  you  dream  of  imaginary  and  of  impossible 

things  ? 

d.  Does  the  same  dream  come  twice  or  more? 

Do  they  change  every  time? 

e.  Are  the  dreams  pleasant  or  disagreeable?    Get 

the  patient  to  describe  as  accurately  as  he 

can  one  or  more  of  his  dreams  and  if  he 

cannot  at  the  time  remember  them,  tell  him 

that  you  will  ask  him  again  about  them  and 

to  try  to  remember  any  that  occur  until  you 

ask  him  again. 

Explanation:  Bring  up  before  the  patient  some  of 

the  things  mentioned  in  the  history  of  his  case  as 

obtained  from  his  relatives  or  physician,  and  get 

him  to  explain  the  events. 

a.  Impulsive  or  peculiar  actions. 

b.  Suicidal  or  homicidal  attempts. 

c.  Hallucinations  and  delusions. 

d.  Moral  laxness. 

e.  Lack  of  judgment. 

Objects. — In  all  this  portion  of  the  examination  the  object 
should  be  to  find  the  meaning  of  the  symptoms.  It  is  not  enough 
to  describe  an  hallucination,  for  example,  its  meaning  should  be 
discovered.  The  dreams  are  a  particularly  valuable  avenue  to  the 
inner  thoughts  and  the  deeper  meanings. 
Special  Tests  : 
Speech: 

Motor- Vocal : 

Does    the    patient   answer   quickly   or   slowly. 
Does  he  stammer,  or  stutter,  or  slur,  or  jum- 
ble his  words?    Is  there  "jargon"  speech? 
Have  him  repeat  some  of  the  following  words 
and  phrases,  and  describe  the  character  of 
the  repetition,  whether  normal,  slurring,  etc. 
Third  riding  artillery  brigade. 
Peter  Piper  picked  a  peck  of  pickled  peppers. 
Conservative.         Perturbation. 
Statistical.  Fastidiousness. 

Irretrievable.  Autobiography. 


}02  OUTLINES   OF   PSYCHIATRY. 

Are  these  twitchings  of  the  facial  muscles,  of 
the  lips,  etc.,  while  the  patient  is  speaking? 
Are  there  tremors? 
Motor- Written : 

Have  the  patient  write  his  name,  the  date  of 
his  birth,  the  city  in  which  he  lives,  the  name 
of  the  present  place,  and  the  date. 

Have  him  write  from  dictation  a  short  sentence 
or  phrase ;  e.  g., 
The  United  States  of  America. 
The  evening  has  come. 
Contentment  is  a  pearl  of  great  price. 
Where  shall  I  find  hope? 

Have  him  copy  one  or  more  typewritten  phrases 
or  words. 
Sensory-Hearing : 

Does  the  patient  understand  what  is  said  to  him 
readily  ? 

Does  he  obey  simple  commands,  e.  g.,  stand  up, 
show  your  tongue,  cross  your  legs,  squeeze 
my  hand?  If  not,  is  it  because  he  does  not 
understand  you  or  is  it  because  he  will  not? 

If  he  obeys  the  simple  commands,  does  he  do 
so  as  readily  the  more  complicated  ones? 
E.  g.,  walk  to  the  other  end  of  the  room, 
turn  about  quickly,  walk  back,  turn  your 
chair  around,  sit  down  and  cross  your  legs. 
Sensory- Visual : 

Does  he  read  words  aloud  correctly  ?  Does  he 
read  numbers,  sentences,  etc.,  correctly? 

Does  he  name  colors  (differentiate  between 
color  blindness  and  inability  to  find  the  name 
for  a  common  color,  e.  g.,  black,  red,  white), 
objects,  and  pictures  correctly? 

Does  the  patient  use  wrong  words  (para- 
phasia) ?  Does  he  have  difficulty  in  getting 
the  name  or  the  word  for  a  thing? 

Does  he  have  a  tendency  to  repeat  certain 
words,  and  do  certain  words  recur  through- 
out the  examination? 


METHODS    OF   EXAMINATION.  3O3 

Apprehension  and  Apperception: 

Summarize  the  results  of  the  examination  of  the  patient 
up  to  this  point  in  respect  to  his  abihty  to  apprehend 
and  to  comprehend  the  situation;  how  much  insight 
into  his  condition  he  has,  whether  he  has  been  quick 
or  slow  to  grasp  the  meaning  of  questions,  whether 
or  not  be  seems  able  to  take  in  more  than  one  thing 
at  a  time. 

Have  the  patient  read  aloud  one  of  the  following  stories, 
ask  him  to  give  the  point  of  it  in  his  own  words. 
Note  how  well  he  does  the  original  reading,  and  record 
accurately  what  he  says  in  giving  the  content  of  the 
story. 

Cowboy  Story — A  cowboy  from  Arizona  went  to  San 
Francisco  with  his  dog,  which  he  left  at  a  dealer's 
while  he  purchased  a  new  suit  of  clothes.  Dressed 
finely,  he  went  to  the  dog,  whistled  to  him,  called  him 
by  name  and  patted  him.  But  the  dog  would  have 
nothing  to  do  with  him  in  his  new  hat  and  coat  but 
gave  a  mournful  howl.  Coaxing  was  of  no  effect,  so 
the  cowboy  went  away  and  donned  his  old  garments, 
whereupon  the  dog  immediately  showed  his  wild  joy 
on  seeing  his  master  as  he  thought  he  ought  to  be. 

Gilded  Boy  Story. — It  is  related  that  at  the  coronation 
of  one  of  the  popes  about  three  hundred  years  ago  a 
little  boy  was  chosen  to  act  the  part  of  an  angel ;  and 
in  order  that  his  appearance  might  be  as  gorgeous  as 
possible  he  was  covered  from  head  to  foot  with  a 
coating  of  gold  foil.  He  was  soon  taken  sick  and 
although  every  known  means  Vv^as  employed  for  his 
recovery,  except  the  removal  of  his  fatal  golden  cov- 
ering, he  died  in  a  few  hours. 

Polar  Bear  Story. — A  female  polar  bear  with  two  cubs 
was  pursued  by  sailors  over  an  ice  field.  She  urged 
her  cubs  forward  by  running  before  them,  and  as  it 
were,  begging  them  to  come  on.  At  last  in  dread  of 
their  capture  she  pushed,  then  carried  and  pitched  each 
before  her,  until  they  actually  escaped.  The  polar 
bear  is  a  wonderful  swimmer  and  diver.     In  the  cap- 


304  OUTLINES   OF  PSYCHIATRY. 

ture  of  seals  lying  on  the  ice,  it  dives  some  distance 
off  and  swimming  underneath  the  water,  suddenly 
comes  up  close  to  the  seals,  cutting  off  their  retreat 
to  the  sea. 
Shark  Story. — The  son  of  a  governor  of  Indiana  was 
first  officer  on  an  Oriental  steamer.     When  in  the  In- 
dian Ocean  the  boat  was  overtaken  hy  a  typhoon  and 
was  violently  tossed  about.     The  officer  was  suddenly 
thrown  overboard.     A  life  preserver  was  thrown  to 
him,  but,  on  account  of  the  heavy  sea,  difficulty  was 
encountered  in  launching  a  boat.     The  crew,  however, 
rushed  to  the  side  of  the  vessel  to  keep  him  in  sight, 
but  before  their  shuddering  eyes  the  unlucky  young 
man  was  grasped  by  one  of  the  sharks  encircling  the 
steamer  and  was  drawn  under  the  water,  leaving  only 
a  dark  streak  of  blood.     (Adapted  from  Ziehen.) 
Good  Girl  Story. — Once  upon  a  time  there  was  a  girl, 
whose  father  and  mother  were  dead,  and  who  was  so 
poor  that  finally  she  had  nothing  but  the  clothes  on  her 
back  and  a  little  piece  of  bread  in  her  hand.     She  was 
deserted  by  everybody,  but  since  she  was  good  and 
honest  she  went  into  the  world  with  confidence  in  God. 
As  she  went  along  she  was  met  by  a  poor  old  man  who 
said,  "  Give  me  something  to  eat,  I  am  hungry."     The 
girl  gave  him  the  piece  of  bread  and  went  on  further. 
Soon  afterwards  she  encountered  a  little  girl  freezing 
and  almost  naked,  who  begged  for  clothes.    The  good 
girl  gave  the  poor  child  the  warmest  of  her  garments. 
Night  came  on,  the  good  girl  was  tried,  cold  and  hun- 
gry.    She  traveled  into  the  woods,  and,  wandering  off 
the  road,  she  knelt  and  prayed  to  God.     As  she  knelt 
she  saw  the  stars  falling  all  about  her,  and  when  she 
looked  she  found  they  were  many  bright  gold  dollars. 
(Adapted  from  Ziehen.) 
Objects. — The  ability  to  repeat  one  of  these  stories  shows  in  a 
rough  way  the  power  of  attention,  the  quality  of  the  interest, 
power  of  memory,  the  tendency  to  elaborate  forgotten  details, 
to  elaborate  the  story  with  invented  additions  and  their  character, 
to  lay  stress  upon  the  emotional  elements,  the  ability  or  failure 
to  see  the  point,  etc.,  etc. 


METHODS   OF  EXAMINATION.  305 

Show  the  patient  for  an  instant  one  of  the  cards  with 
collections  of  figures,  letters,  pictures,  etc.,  such  as  are 
illustrated  below,  and  have  him  tell  you  what  is  on 
the  card,  giving  the  content  in  full  and  the  relative 
positions  of  the  different  elements. 

The  following  apperception  test  may  be  used  if  it  seems 
desirable.  In  this  test  the  patient  is  given  a  sheet  on 
which  is  printed  an  anecdote,  story  or  description,  but 
in  which  certain  words  are  left  blank.  The  patient  is 
to  be  instructed  to  go  over  the  paper  carefully  and 
after  having  once  gone  over  it  to  fill  in  the  spaces  with 
words  that  will  appropriately  give  the  meaning  to  the 
story. 

1.  Once  upon  a  time  heard  a  chirruping 

in  the .     Ah,  he  said  to  himself,  if  I  could 

like  that,  how  I  should  be.     So  he 

bowed  low  to  the  ,  and  said,  kind  friend, 

what do  you  eat  to  make  your so  sweet? 

I  drink  the  evening  dew,  replied  the .     The 

foolish  tried  to  live  on  the  same ,  and 

died  of . 

2.  Monkeys  are and creatures  when  , 

but  become  and  as  they  grow 


especially  the  males.     They  pass  most  of  their 

time  in  alternate  and ;  after  a  violent 

they  change  to  the  other  extreme,  and  be- 
have as  if  they  were  the  most of  creatures. 

Animals  at  one  moment  living  in  perfect  

and become  in  an  instant  deadly ,  ready 

to each  other  to . 

During  the  early  centuries  of  Christian  Spain  the 

conditions  of  the were  such  that  every 

was   obliged  to   defend  his  to  the  throne 

against  the  of  his  family,  so  that  almost 

constant were  being  waged  among  the  near- 
est kin  and  it  was  practically  impossible  that  sev- 
eral   of  weak  and  incompetent  should 

not  have  been  wrested  from  the  throne. 


3o6 


OUTLINES   OF  PSYCHIATRY. 


1  4  9 


3  7  4 
9  1  5 


O  T 
R  C 


GREEN  TREE 


3  6 
1  4 


B  N  V 


HOUSE 


DOG 

MOUSE 

CAT 


METHODS   OF   EXAMINATION.  30/ 

Attention: 

Summarize  the  results  of  the  observations  made  during 
the  examination  of  the  patient.  Describe  the  char- 
acter of  any  apparent  attention  disorder,  and  if  pos- 
sible give  examples  to  show  the  character.  In  the 
summary  try  to  differentiate  between  what  is  known 
as  "  distractibility,"  wandering  attention,  or  the  shift- 
ing of  the  attention  to  successive  new  impressions, 
and  the  lack  of,  or  the  fluctuations  of  the  attention 
such  as  is  found  in  senile  and  alcoholic  (Korsakow's 
syndrome)  conditions. 
Should  there  be  an  apparent  fluctuation  of  the  attention 
try  one  of  the  following  tests,  to  bring  out  the  condi- 
tion in  a  more  graphic  manner. 

I.  Read  to  the  patient  the  following  series  of  numbers 
at  the  rate  of  one  each  half  second,  or  the  series 
of  letters  in  the  same  way  and  have  him  tap  with 
a  pencil  each  time  the  number  6  or  the  letter  C  is 
read  as  the  case  may  be. 


4 

3 

6 

8 

5 

9 

6 

3 

4 

6 

5 

2 

4 

7 

6 

5 

8 

6 

7 

2 

3 

6 

6 

3 

7 

6 

3 

9 

3 

8 

6 

7 

3 

6 

9 

3 

5 

6 

4 

8 

8 

6 

9 

4 

6 

8 

9 

4 

6 

7 

9 

7 

8 

4 

6 

8 

5 

9 

8 

6 

5 

3 

2 

8 

6 

9 

8 

3 

6 

9 

7 

2 

8 

6 

7 

6 

4 

3 

8 

5 

7 

9 

2 

6 

5 

7 

2 

8 

6 

2 

8 

7 

6 

9 

6 

4 

3 

7 

2 

8 

TCQNDCBKCJCHAFLCOSMB 
CRFKCLHDACJQSMTCCNFO 
BJCMKRCTAHCDLQCRNCOJ 
CACFKOQHCMLFDCSRCNTB 
SFCTJLCHNAQCRTCKCDBS 
Note  each  time  a  letter  or  a  number  is  not  prop- 
erly responded  to,  and  see  if  there  is  a  rhythm  in 
the  failure  to  make  the  response. 

Have  the  patient  tap  on  the  tapping  apparatus, 
which  is  a  mechanical  counter,  for  thirty  seconds 
and  record  the  number  of  taps  that  he  makes  in 
different  periods  of  five  seconds. 

Or,  have  him  make  taps  on  a  sheet  of  paper  to  and 
fro  for  thirty  seconds,  and  note  how  long  it  takes 
him  to  tap  along  one  line. 


308  OUTLINES   OF   PSYCHIATRY. 

Or,  have  him  make  the  taps  in  the  squares  of  a 
sheet  of  cross  section  paper  (having  each  square 
about  half  an  inch  wide),  noting  how  long  it  takes 
him  to  make  the  successive  ten  taps,  in  the  total 
series  of  lOO  taps. 
Memory: 

Summarize  the  results  of  the  questions  which  indicate 
the  memory  grasp  of  the  patient.  Include  under  sepa- 
rate headings  accounts  of  the  following: 

1.  Recent  and  remote  events. 

2.  Names  of  persons,  including  members  of  his  family, 

the  physicians,  nurses  and  attendants,  and  other 
parties. 

3.  Date  and  time. 

4.  Places. 

Should  there  appear  to  be  any  memory  defect  try  the 
following  tests : 

1.  Have  the  patient  read  aloud  a  number  of  four  digits, 

or  read  the  number  to  him,  speaking  each  digit 
separately.  This  will  give  respectively  the  visual 
and  the  auditory  memories. 

5632  9764  3521 

8629  5941  7368 

6214  9826  5327 

2.  If  the  patient  can  retain  all  of  the  four  digits  try 

him  with  the  six  or  eight  digit  combinations. 

487631  736491                571924 

955217  972864                249837 

276384  845193                516724 

45319628  19362874  29317586 

35984271  92576438  83264519 

97125684  63258914  87635219 

3.  Give  combinations  of  three  associated  words  and 

have  the  patient  repeat  them  after  you  as  well  as 
he  can. 

Cloak,  hat,  and  gloves. 

Enemy,  battle,  and  peace. 

Station,  train,  and  conductor. 


METHODS   OF  EXAMINATION.  309 

Deer,  horn,  and  hoof. 

Wall,  brick,  and  ivy. 
Another  test  that  may  be  tried  is  the  use  of  two 
or  more  pairs  of  associated  words  of  which  the 
patient  is  to  remember  the  second  one  of  the  pair. 
The  pairs  are  read  to  the  patient,  he  is  required 
to  repeat  them,  and  after  the  series  (which  may 
be  made  up  of  two,  three,  four  or  more  pairs)  has 
been  gone  over  he  is  given  the  first  word  of  a  pair 
and  asked  what  word  goes  with  it.  The  follow- 
ing pairs  of  words  may  be  used  in  any  combina- 
tion of  two,  three,  four,  etc. 

Well — pump.  Soap — towel. 

Cent — dime.  Book — paper. 

Roast — stew.  Child — doll. 

Oak — pine.  Friend — companion. 

Drug — medicine.  Bees — ants. 

Game — sport.  Red — brown. 

Bridge — river.  Law — judge. 

Dust — sand.  Duck — ^water. 

Thumb — toe.  Square — round. 

Cow — horse.  Face — beard. 

Water — ice.  Actor — theater. 

Barrel — ^bottle.  Glove — hand. 

Porch — chair.  Potatoes — fish. 

Glue — ^wood.  Stone — earth. 

Street — house.  Tea — sugar. 

Have  the  subject  repeat  the  following,  and  record 
exactly  what  he  says: 

The  alphabet. 

The  names  of  the  months. 

The  days  of  the  week. 

The  names  of  the  seasons. 

The  Lord's  prayer. 
Examine  the  patient  in  regard  to  his  memory  of 
school  subjects,  especially  geography  and  history. 

Which  is  the  longest  river  in  the  U.  S.? 

What  is  the  capital  of  the  U.  S. 

Name  some  of  the  most  important  countries  in 
Europe. 


3IO  OUTLINES   OF  PSYCHIATRY. 

Name  the  largest  cities  in  the  U,  S.  and  in  the 

different  countries  of  Europe. 
Give  the  dates  of  the  most  important  wars  of 
the  United  States,  and  with  what  countries 
were  they  fought. 
Name  some  of  the  most  noted  presidents,  etc., 
etc. 
7.  In  addition  to  the  anecdotes  that  were  used  in  the 
apperception  and  apprehension  tests,  which  give 
a  good  idea  of  the  memory  grasp,  have  the  sub- 
ject give  the  substance  of  one  or  more  of  the  fol- 
lowing sentences  or  anecdotes : 

The  game  of  base-ball  is  fast  taking  hold  of 
the  people  of  Canada,  who  hitherto  have  been 
satisfied  with  the  English  games  of  cricket 
and  foot-ball. 
The  Hindoos  believe  that  the  gradual  darken- 
ing of  the  sun  during  an  echpse  means  that 
the  jaws  of  a  dragon  are  gradually  eating 
it  up. 
Without  map  or  compass  the  swallows  come 
back  each  year  to  the  places  that  have  pre- 
viously sheltered  them. 
The  advocates  of  universal  peace  will  go  to 
all  sorts  of  extremes  to  get  their  views  ac- 
cepted, for  they  will  fight  those  who  dare  to 
disagree  with  theiri. 
Pen,  ink,  pencil  and  paper  have  been  the  most 
potent    factors    in   the   advancement   of   the 
world  in  every  way. 
Association: 

The  associations  of  the  patient  may  be  determined  from 
the  general  examination,  from  the  accounts  of  the 
stories  used  in  the  tests  of  apperception  and  apprehen- 
sion, especially  the  test  of  filling  in  the  blank  spaces  on 
p.  305,  from  the  mistakes  made  in  answer  to  the  mem- 
ory tests  on  pp.  296,  297,  and  298.  For  more  exten- 
sive tests  the  following  series  of  words  may  be  used. 
The  patient  should  be  instructed  to  say  the  first  word 


f 

METHODS   OF  EXAMINATION.  3  II 

or  idea  that  comes  into  his  mind  when  he  hears  a  test 
word  that  is  given  him.  It  is  advisable  often  to  make 
note  of  the  time  between  the  giving  of  the  test  word 
and  the  response  of  the  patient.  This  can  be  obtained 
sufficiently  accurately  by  observing  the  second  hand  of 
a  watch  at  the  time  of  the  experiment.  In  this  work 
it  is  very  important  that  the  replies  of  the  patient  be 
recorded  exactly  as  they  are  given.  If  there  seems  to 
be  no  apparent  connection  between  the  association  of 
the  patient  and  the  test  word  that  has  been  given  to 
him,  try  to  get  him  to  trace  for  you  the  connection 
that  has  gone  on  in  his  mind ;  for  example,  should  you 
give  him  the  word  "  apple  "  and  he  replied  "  foot,"  the 
connection  is  not  one  that  can  readily  be  recognized, 
but  if  on  questioning  you  find  that  the  word  "  apple  " 
suggested  to  him  a  time  when  he  was  under  an  apple 
tree  and  he  walked  on  a  number  of  rotting  apples  with 
his  bare  feet,  the  association  is  more  easily  understood. 


I. 

White.     Red.     Gray.     Dark.     Light. 

2. 

Pain.     Rest.     Cold.     Sweet.     Beautiful, 

3- 

Head.     Poor.     Man.     King.     Hair. 

4- 

Chair.     Bed.     House.     Lamp.     Stairs. 

5- 

Mountain.     River.     Sea.     Sun.     Star. 

6.  Tree.     Leaf.     Grass.     Bush.     Flower. 

7.  Luck.     Sick.     Hate.     Fear.     Right. 
Determination  of  Submerged  Complexes: 

The  method  of  procedure  is  to  take  a  list  of  words,  from  one 
to  two  hundred,  and  then  while  reading  the  words  to  the 
patient,  he  having  been  told  to  tell  immediately  what  comes 
into  his  mind  after  hearing  the  word,  record  the  time  taken 
in  forming  the  association.  The  most  practical  way  for 
recording  the  time  is  by  a  stop-watch  graduated  to  fifths  of  a 
second.  After  the  list  has  been  completed  it  may  be  repeated 
in  the  same  way,  the  patient  being  asked,  however,  to  give 
the  same  associations  he  did  the  first  time  if  he  can  recall 
them.     The  time  need  not  be  recorded  for  the  repetition. 

When  one  of  the  words  in  the  list  touches  a  complex,  is  a 
complex  indicator,  marked  disturbances  in  association  are 
noted.     These  disturbances  are:  (i)  Increased  length  of  re- 


312 


OUTLINES   OF   PSYCHIATRY. 


action  time;  (2)  superficiality  of  the  association;  (3)  for- 
getting of  the  association  00  repetition;  (4)  peculiarity  of 
the  type  of  reaction,  i.  e.,  the  association  may  have  some 
direct  association  with  the  complex  but  no  apparent  associa- 
tion with  the  word  given;  (5)  the  irradiation  of  the  disturb- 
ance to  the  next  one  or  two  associations.  Other  disturbances 
occur,  but  these  are  the  principal  ones. 
The  following  shows  some  of  the  disturbances.  The  patient 
was  suicidal,  having  made  several  attempts  at  self-destruc- 
tion.    Her  average  reaction  time  was  about  1.6  sec. 


Stimulus  word. 

Reaction. 

Time. 

Reproduction. 

To  harm 

self 

6.6 

any  one 

stork 

large 

4.4 

large 

false 

true 

1.8 

not  true 

In  this  example  the  extreme  length  of  reaction  time  is  shown 
(6.6  sec),  inability  to  recall  the  reaction  on  repetition,  and 
irradiation  of  the  disturbance  to  the  next  two  reactions  as 
shown  by  their  increased  length. 

The  same  patient  had  been  made  very  unhappy  on  one  occasion 
by  the  arrest  of  her  brother,  his  arraignment  in  court,  and 
the  neecssity  of  giving  bond  for  him.  Note  the  following 
reactions:  prison — cell — ^4.2  sec;  barn  (understood  as  bond) 
—pay — 4.6  sec:  judge — to  be  judged — 4  sec. 

The  following  words  may  be  used,  interspersing  words  here 
and  there,  if  thought  desirable,  which  are  believed  to  have 
special  significance. 

31  Sympathy: 

32  Yellow: 
Z2  Mountain: 

34  To  play: 

35  Sail: 
2,6  New : 
Z7  Custom : 

38  To  ride: 

39  Wall : 

40  Stupid : 

41  Volume : 

42  To  despise: 

43  Teeth: 

44  Correct : 

45  Crowd: 


I  Head: 

16  Sick: 

2  Green: 

17  Proud: 

3  Water: 

18  To  boil: 

4  To  prick : 

19  Ink: 

5  Angel: 

20  Angry: 

6  Long: 

21  Needle: 

7  Ship: 

22  To  swim: 

8  To  plough: 

23  Journey: 

9  Wool : 

24  Blue: 

ID  Friendly: 

25  Bread: 

II  Table: 

26  To  threaten : 

12  To  carry: 

27  Rich: 

13  Insolent: 

28  Lamp: 

14  To  dance: 

29  Tree: 

15  Lake: 

30  To  sing: 

METHODS  OF  EXAMINATION. 


313 


46  Book: 

47  Unjust: 

48  Frog: 

49  To  cut: 

50  Hunger: 

51  White: 

52  Ring: 

53  To  listen: 

54  Pencil: 

55  Woods: 

56  Apple: 

57  To  meet : 

58  Law: 

59  Love: 

60  Glass: 

61  To  quarrel; 

62  Goat: 

63  Large: 

64  Potato: 

65  To  paint: 

66  Part: 

67  Old: 

68  Flower: 

69  To  strike: 

70  Box: 


71  Wild: 

72  Bright: 

73  Family: 

74  To  wash: 

75  Cow: 

76  Stranger: 

77  Luck: 

78  To  tell: 

79  Hesitation: 

80  Narrow: 

81  Brother: 

82  To  harm: 

83  Stork: 

84  False: 

85  Anxiety: 

86  To  kiss: 

87  Fire: 

88  Dirty: 

89  Door: 

90  To  choose: 

91  Hay: 

92  Quiet: 

93  Scorn: 

94  To  sleep : 
.  95  Month : 


96  Colored: 

97  Dog: 

98  To  talk: 

99  Carriage: 

00  Sky: 

01  Straw: 

02  Baby: 

03  To  lie : 

04  Blood: 

05  Duty: 

06  Bed: 

07  To  rent: 

08  Sorrow: 

09  Mirror: 

10  Judge: 

11  Knee: 

12  To  live: 

13  Change: 

14  Barn: 

15  Snake: 

16  To  uncover: 

17  Policeman: 

18  Wagon: 

19  Judge: 

20  Night: 


Thinking: 

In  a  previous  section  the  patient  has  described  his  feel- 
ings regarding  his  abihty  to  think  properly  and  easily. 
These  feelings  may  or  may  not  corespond  to  the 
actual  state  of  affairs.  There  may  be  a  feeling  of 
ability  without  the  ability  of  performance,  and  there 
may  be  the  feeling  of  inability  without  any  actual 
change  in  the  real  ability.  The  calculation  tests  of 
age,  date  of  birth,  etc.,  may  be  used  to  get  some  idea 
of  the  ability  of  the  patient  to  think  well,  but  these 
figures  are  so  often  used  that  it  is  not  necessarily  true 
that  if  he  gives  them  correctly  he  retains  his  normal 
thinking  ability.  For  further  testing  the  following 
calculations  are  easy  tests  to  apply. 
Addition. 

Add    73  and  22 

Add    90  and  18 


314  OUTLINES   OF   PSYCHIATRY. 

Add  84  and  25 
Add  106  and  17 
Add  137  and  64 

Subtraction. 

Subtract  7  from  63 
Subtract  16  from  192 
Subtract  24  from  87 
Subtract  35  from  257 
Subtract  19  from    96 

Division. 

Divide  63  by  7 

Divide  45  by  5 

Divide  132  by  11 

Divide  192  by  16 

Divide  15  by  3 

Multiplication. 

Multiply    7  by  9 

Multiply     9  by  13 

Multiply  12  by  15 

Multiply  14  by  11 

Multiply    8  by  13 

In  cases  in  which  it  is  possible  to  give  the  following 
logical  tests,  these  may  very  well  be  used  to  deter- 
mine any  defect  in  thinking.  The  patient  is  to  be 
instructed  to  read  carefully  the  passages  which  are 
given  on  the  sheet,  and  to  say  whether  or  not  the 
conclusion  of  each  of  them  is  correct.  No  attempt 
need  be  made  to  get  him  to  name  or  to  correct  the 
logical  errors,  but  if  the  corrections  are  volunteered 
they  should  be  noted. 

1.  All  roses  are  beautiful;  lilies  are  not  roses;  there- 

fore lilies  are  not  beautified. 

2.  Nothing  is  better  than  wisdom ;  dry  bread  is  better 

than  nothing;  therefore  dry  bread  is  better  than 
wisdom. 

3.  None  but  savages  were  in  America  when  it  was 

discovered;   Hottentots   are   savages,  and  must, 


METHODS   OF   EXAMINATION.  315 

therefore,  have  been  in  America  when  it  was  dis- 
covered. 

4.  Repentance  is  a  good  quality;  wicked  men  abound 

in  repentance,  and,  therefore,  abound  in  what  is 
good. 

5.  The  object  of  war  is  durable  peace;  therefore  sol- 

diers are  the  best  peacemakers. 

6.  No  soldiers  should  be  brought  into  the  field  who 

are  not  w-ell  qualified  to  perform  their  duty ;  none 
but  veterans  are  well  qualified  to  perform  their 
part,  and,  therefore,  none  but  veterans  should  be 
brought  into  the  field. 
Ethical  Questions. 

If  you  saw  a  man  drop  a  $io  bill  on  the  sidewalk,  what 

would  you  do? 
What  do  you  understand  is  the  difference  between  right 

and  wrong? 
Why  is  it  wrong  to  steal? 
Examination  of  Stuporous  Cases. 
General  attitude: 

Position  of  body: 
sitting. 

lying — on  back,  side,  face. 
Disposition  of  limbs. 

Evidences  of  paralysis — hemiplegia,  facial,  ocular? 
Voluntary  musculature — flaccid,  contractured? 
Evidences  of  catatonic  rigidity? 
Tremors. 
Face: 

Expression — changeable  or  fixed,  mask-like,  pained  ? 
Grimacing — Schnauzkrampf  ? 
Position  of  eye-balls — rolled  up  under  lid? 
Reflexes: 

Superficial  and  deep.     Compare  two  sides. 
Pupillary. 
Winking. 
Tickling. 
Reactions 

Can  the  patient  be  brought  to  maintain  a  position 
requiring  volitional  control  ? 


3l6  OUTLINES    OF    PSYCHIATRY. 

Does  the  patient  voluntarily  correct  uncomfortable 

positions? 
Does  the  patient  show  any  emotional   (expressive, 
vasomotor,  circulatory,  respiratory)    response  to 
bad  news,  jokes? 
Do  patient's  eyes  follow  examiner? 
Does  patient  take  food? 

Are  his  actions  the  same  when  apparently  not  ob- 
served as  when  under  observation? 
Does  patient  respond  to  calls  of  nature? 
Does  he  retain  saliva?    Drooling? 
Are  there  any  spontaneous  acts  ?    Why  ? 
Objects. — Having  envisaged  the  individual  from  every  point  of 
view  it  is  valuable  to  summarize  the  findings  and  desirable,  if  pos- 
sible, to  give  a  name  to  the  psychosis.     It  must  always  be  borne 
in  mind,  however,  that  naming  is  merely  for  convenience  of  desig- 
nating the  group  to  which  the  condition  belongs.     Names  too  fre- 
quently become  obsessions  and  naming  an  end.    The  essential 
thing  is  that  the  psychosis  should  have  been  explained,  its  mean- 
ing reached  by  an  uncovering  of  the  mechanisms  involved. 


CHAPTER  XX. 

A  Minimum  Mental  Examination. 

In  hospitals  that  admit  large  numbers  of  patients  annually  and 
in  which  the  personnel  of  the  medical  staff  is  continually  changing 
it  becomes  necessary  to  adopt  some  standard  scheme  of  examina- 
tion of  the  patients  for  several  reasons.  Of  the  innumerable 
things  that  might  be  required  in  such  an  examination  many  have 
only  occasional  value  and  many,  in  the  nature  of  the  case,  could 
not  be  required  at  all.  It,  therefore,  becomes  necessary  in  outlin- 
ing any  scheme  for  general  application  to  have  in  view  only  a 
minimum  requirement.  In  other  words,  so  much  at  least  shall  be 
done  in  every  case  and  as  much  more  as  the  examiner  desires  or 
the  necessities  of  the  case  indicate. 

A  standard  examination  soon  becomes  familiar  to  all.  In  using 
it  one  is  less  likely  to  leave  out  essentials,  as  very  often  happens 
when  the  examination  is  conducted  in  a  desultory  way  without 
any  plan  of  procedure.  Certain  portions  of  the  examination,  as 
for  example  the  stories,  can  merely  be  referred  to  by  name  and  do 
not  have  to  be  repeated  each  time,  such  as  the  cowboy  story,  the 
good  girl  story,  etc.  (See  pp.  303-4.)  Every  one  knows  these 
tests  by  heart  and  the  response  of  the  patient  is  all  that  needs  to 
be  recorded.  Then  again  the  standard  examination  gives  a  better 
basis  of  comparison  between  different  patients,  particularly  those 
suffering  from  similar  conditions.  It  is  also  a  means  of  calibrat- 
ing, so  to  speak,  the  individual  patient  at  different  periods  of  his 
malady.  The  same  mental  tests  gone  through  with  at  different 
times  gives  an  excellent  idea  of  whether  the  patient's  condition  is 
changing  or  not  and  indicate,  too,  something  of  the  nature  of  the 
change.  With  a  standard  method  it  is  much  easier  to  initiate 
new  men  as  they  come  on  the  staff.  They  find  the  scheme  in  full 
operation  and  soon  fall  into  using  it.  This  renders  them  highly 
valuable  at  a  time  when  they  would  be  comparatively  useless  if 
merely  permitted  to  drift  and  suit  their  own  inclinations.  This 
last  reason  is  a  particularly  strong  one  in  hospitals  for  the  insane, 

317 


3l8  OUTLINES   OF    PSYCHIATRY. 

where  the  whole  problem  is  so  different  from  that  in  the  general 
hospital. 

The  principal  value  that  a  scheme  of  examination  may  have, 
however,  is  in  formulating  tests  that  call  for  an  actual  record  of 
the  patient's  reactions  and  not  the  conclusions  of  the  examiner. 
Our  mental  examinations  are  filled  with  such  remarks  as  "the 
patient  shows  lack  of  judgment"  or  is  "  disoriented"  or  has  "  fail- 
ure of  memory."  All  of  these  are  conclusions  and  by  no  means 
records  of  fact.  Such  histories  are  useless  to  any  one  except 
perhaps  the  person  who  wrote  them.  The  reader  of  a  history  is 
entitled  to  a  statement  of  the  facts  on  which  the  conclusion  is 
based  and  then  he  is  at  liberty  to  form  his  own  conclusions  from 
the  identical  premises.  How  much  better  and  more  accurate  than 
the  statement  "  defective  memory  "  would  be  this  test :  The  patient 
in  the  course  of  the  examination  is  given  the  address,  375  Oxford 
St.  After  five  minutes  he  is  asked  to  recall  it.  He  gives  the 
number  176,  but  cannot  give  the  name  of  the  street  at  all.  Here 
is  a  definite  fact.  A  multiplicity  of  such  facts  gives  any  one  a 
basis  for  conclusions  about  the  patient.  Of  such  statements 
should  the  record  of  an  examination  be  composed. 

The  following  scheme,  which  is  largely  the  work  of  Dr.  S.  I. 
Franz,  is  the  one  now  in  use  in  Saint  Elizabeths  Hospital. 

It  is  recommended,  for  hospitals  for  the  insane,  that  the  follow- 
ing tables  be  prepared  in  chart  form  and  hung  up  in  the  exami- 
nation room: 

I.    FAMILY  HISTORY. 

Informant:  (name,  relationship  to  patient,  address). 
Grandparents:  Parents:   (uncles  and  aunts),  Siblings: 
Children:  (with  abortions  and  miscarriages). 

In  securing  the  family  history  it  must  be  remembered  that  it  is 
equally  important  to  get  a  record  of  all  the  normal  members  of 
the  family  as  well  as  the  abnormal  and  not  stop  with  securing  the 
latter,  as  is  often  done.  The  patient's  relation  to  hereditary  ten- 
dencies can  only  be  determined  by  securing  information  about  his 
ancestors.     For  example,  Heron^  has  shown  that  the  liability  to 

1  David  Heron,  M.A. :  A  First  Study  of  the  Statistics  of  Insanity  and 
the  Inheritance  of  the  Insane  Diathesis.  Eugenics  Laboratory  Memoirs, 
II.    University  of  London. 


A   MINIMUM    MENTAL  EXAMINATION.  3I9 

insanity  in  children  from  insane  stock  is  greatest  among  the  earlier 
born  and  falls  off  rapidly,  particularly  after  the  fourth  child. 

II.    HISTORY  OF  PATIENT. 

Full  Name  :  Address  :  Occupation  : 

BiKTH :  Childhood  Diseases  :  Learned  to  Walk  and  Talk  : 

Diseases:  (especially  convulsions,  delirium,  head-injury,  gonorrhoea,  syph- 
ilis, rheumatism,  neuritis). 

Habits:   (alcohol,  drugs  and  sexual). 

Marriage  :  Menstruation  :  Gynecological  : 

Previous  Attacks  :  (special  attention  to  so-called  hysterical,  to  breakdown, 
and  to  melancholic  periods). 

Ciumes  and  Misdemeanors: 

Mental  Make-up: 

The  history  of  the  patient  is  especially  important  for  getting  a 
comprehensive  idea  of  the  sort  of  person  the  patient  was  before 
becoming  psychotic.  A  given  mental  disorder  cannot  be  fully 
understood  without  understanding,  not  only  the  circumstances 
that  gave  rise  to  it,  but  the  other  and  more  important  factor,  the 
make-up  of  the  individual  in  whom  the  disorder  occurs. 

III.    PRESENT  ILLNESS. 

Onset:  Cause:  Physical:  Mental  and  Moral  Changes: 
Emotional  Condition  :  Hallucinations  and  Delusions  : 
Judgment:  Memory:  Suicide  and  Homicide:  Insight: 

Under  this  head  is  made  an  inquiry  into  all  the  circumstances 
surrounding  and  conditioning  the  onset  of  the  psychosis  and  the 
patient's  attitude  toward  them  and  his  insight.  He  should  be 
asked  frankly  whether  he  believes  himself  mentally  ill ;  if  not,  how 
is  it  that  he  has  been  sent  to  a  hospital  for  the  insane;  what  he 
may  have  done  or  said  to  lead  others  to  think  him  insane ;  what  is 
his  explanation  of  the  whole  situation  and  how  it  all  came  about. 

IV.    GENERAL  OBSERVATIONS.' 

Facial  Expression  :  Appearance  and  Demeanor  :  Movements  : 
Speech  :  Mental  : 

The  general  observation  of  the  patient  is,  of  course,  always  im- 
portant; whether  he  appears  silly,  resentful,  indifferent;  whether 


320  OUTLINES   OF   PSYCHIATRY. 

he  has  mannerism,  etc.  It  is  particularly  important,  however,  in 
stuporous  and  delirious  patients  who  either  will  not  speak  or  are 
not  responsive  and,  therefore,  not  accessible.  These  patients 
should  be  observed  particularly  as  to  their  general  attitude  of  body 
and  limbs,  the  expression  of  the  face,  the  reflexes,  and  the  reac- 
tions— volitional,  emotional,  and  organic  (hunger,  sexual,  respond- 
ing to  calls  of  nature,  etc.). 

V.    GENERAL  PHYSICAL  EXAMINATION. 

FoEM :  Nutrition  :  Weight  :  Height  :  Skin  :  Bones  and  Joints  : 

Decubitus:  Scars:  (especially  penis  and  mouth). 

Respiratory  System  : 

Circulatory  System  :  Heart-position  ;  Size  and  Sounds  ;  Blood-pressure  : 

Genito-xjrinary  System  : 

Gastro-intestinal  Tract:   Stomach  Content   (if  indicated):   Glands: 

Abdomen  : 
Sputum:  (if  indicated).    Blood  Composition:  (if  indicated). 
Cerebrospinal  Fluid:  (if  indicated). 
Urine:  (always). 

It  is  hardly  necessary  to  insist  upon  the  necessity  for  a  thorough 
physical  examination  in  every  case.  It  is  especially  important  in 
the  deliria  in  which  the  mental  disorder  may  be  the  expression  of 
an  obcsure  physical  condition. 

VI.    NEUROLOGICAL  EXAMINATION. 

Atrophy:  Hypertrophy: 

Movements,  Voluntary:  activity;  rapidity;  accuracy;  force;   (especially 

paresis)  ;  limitations. 
Movements,  Involuntary:  rigidity;  tremor  (at  rest,  intention);  spasms; 

convulsions. 
Reflexes:  KK;'^   TA  ;  contralat.   add.;   plantar;   cremasteric    (inguinal); 

bladder;  anal;  epigastric;  triceps;  ulnar;  radial;  jaw;  clonus;   (ankle, 

patellar  and  wrist). 
Nerve-trunk  Sensitiveness:  Tender  Areas:  (especially  vertebrae,  breast, 

ovarian). 
Coordination:  FN;  FF;  FT;  KH;  station   (eyes  open  and  closed,  one 

and  both  feet)  ;  gait. 
Sensations:    touch;    pain;    organic;    paresthesia;    hypesthesia;    hyperes- 
thesia; anesthesia;  analgesia;  sense  of  position;  feeling  of  reality. 

2  KK  =  knee  kick.  TA  =  tendo-Achilles.  FN  =  finger  nose.  FF  =  finger 
finger.    FT  =  fingers  thumb.    KH  =  knee  heel. 


A    MINIMUM    MENTAL   EXAMINATION.  321 

Cranial  Nerves: 

1.  Smell:  solutions  and  subjective. 

2.  Hemiopia :  fundus ;  hallucinations. 

3.  4,  6.  Eye  movements  (all  directions):  squint;  diplopia;  ptosis;  nys- 

tagmus (horizontal,  vertical,  rotary). 
Pupils:  size;  outline;  direct  light;  consensual  light;  accommodation; 
sympathetic. 
5.  Corneal  reflex:  chewing  movements;  taste;  solutions  and  subjective. 

7.  Facial  symmetry:    (whistling);  tremors;  test-phrases. 

8.  Hearing:  objective  and  subjective  vertigo. 

9.  10,  II.  Swallowing:  pharyngeal  reflex. 
12.  Protrusion  of  tongue. 

In  a  condition  which  admittedly  involves  the  central  nervous 
organs,  particularly  the  brain,  the  neurological  examination  be- 
comes of  the  greatest  importance.  Especial  importance  should  be 
paid  to  the  cranial  nerve  distributions  and  to  the  presence  of 
paralyses  or  anesthesias,  which  might  have  localizing  significance. 

VII.    MENTAL  EXAMINATION. 

Orientation  :  time ;  place ;  people. 

General  Memory:  family;  school;  occupation;  marriage;  children;  dis- 
eases. 

Emotional  Status  :  insight ;  sleep ;  dreams. 

Hallucinations:  auditory;  visual;  other  senses. 

Speech:  voluntary;  naming;  writing;  (name,  date,  the  U.  S.  A.,  the  Com- 
monwealth of  Mass.);  auditory;  visual;  test-phrases.  (Statistical,  per- 
turbation, 3d  Riding  Artillery  Brigade.) 

Stories:  (Cowboy,  Gilded  Boy,  Polar  Bear,  Shark,  Good  Girl). 

Special  Memory:  (Civil  War;  name  of  two  generals;  three  European 
countries;  capital  of  native  State;  President;  45319628;  35984271; 
487631;  955217;  7368;  9826;  487;  352;  375  Oxford  Street;  (after  3  or  5 
minutes). 

Masselon  :  (hunter,  dog,  gun,  forest,  rabbit;  man,  wood,  coal,  stove, 
dinner;  needle,  thread,  button,  vest;  pipe,  match,  smoke;  pen,  ink, 
letter). 

Ziehen:  (horse  and  ox;  dwarf  and  child;  lie  and  mistake;  water  and  ice). 
7X6;  56—18;  23  —  14;  81—9;  X  — 5  =  17;  X  — 8=13;  have  50c.; 
buy  cherries  12c.,  butter  Tz.,  bread  loc. ;  how  much  change? 

Forward  and  Backward  Associations:  (month;  days  of  week;  752186, 
35729,  6418,  265,  497). 

General  Information:  cost  of  postage;  color  of  stamps;  holidays  and 
meaning:  (Christmas,  Easter,  4th  of  July). 


322  OUTLINES   OF  PSYCHIATRY. 

Fimckh:   ("The  early  bird  catches  the  worm";  "Lies  have  short  legs"; 

"Set  a  thief  to  catch  a  thief";  "Burn  a  candle  at  both  ends"). 
Ethical  Questions: 
DRAWING:  Diagram:   (after  5  seconds'  exposure). 

Here  especial  caution  is  needed  to  avoid  recording  conclusions. 
For  example:  Under  orientation  the  patient's  actual  answers  to 
such  questions  as,  When  were  you  born  ?  How  old  are  you  ?  What 
day  is  this  ?  etc.,  should  be  put  down. 

The  stories  which  are  used  have  been  selected  with  great  care. 
They  are  especially  valuable.  It  is  remarkable  the  amount  of 
information  that  one  can  obtain  from  getting  a  patient  to  repeat 
one  or  tv%'o.  Defects  of  memory  and  attention  show  immediately, 
while  the  manic  tendency  to  elaborate  is  characteristic.  They 
should  never  be  omitted.  The  cowboy  story  is  usually  the  easiest, 
while  the  good  girl  story  is  hard,  because  of  the  great  amount 
of  detail.  The  emotional  feature  of  the  "  streak  of  blood  "  in  the 
shark  story  is  particularly  impressive  and  is  often  about  the  only 
feature  of  the  story  reproduced. 

In  the  special  memory  test,  of  course,  different  people  will  have 
to  be  treated  differently.  A  Polish  immigrant  just  landed  would 
hardly  know  about  the  Civil  War.  The  important  thing,  how- 
ever, is  to  record  actual  question  and  answer. 

In  the  Masselon  test  the  patient  is  asked  to  incorporate  such 
words  as  pen,  ink,  letter,  into  a  sentence.  In  the  Ziehen  test  the 
patient  is  asked  to  tell  the  difference  between  horse  and  ox,  dwarf 
and  child,  etc. 

The  problem  of  calculating  the  change  left  from  50c.  after 
making  certain  purchases  is  an  excellent  example  of  the  useful- 
ness of  standard  questions.  Every  one  on  the  staff  knows  that 
the  answer  is  21c.;  and  although  this  is  a  little  thing;  when 
multiplied  many  times  it  makes  a  great  deal  of  difference  in  the 
ease  with  which  one  can  go  over  a  history  or  appreciate  it  when 
read. 

The  forward  and  backward  associations  are  valuable  as  roughly 
quantitative.  The  average  person  should  be  able  to  give  six  num- 
bers forward  and  five  numbers  backward.  This  test  will  disclose 
just  how  many  the  patient  can  give  and  is  one  of  the  valuable  tests 
for  repeating  from  time  to  time  during  the  course  of  the  psychosis. 
It  is  also  very  valuable  in  detecting  the  malingerer.    A  definite 


A   MINIMUM    MENTAL  EXAMINATION.  323 

intention  to  blunder  is  usually  readily  distinguishable  from  a  nat- 
ural blunder. 

In  the  Finckh  test  the  patient  is  asked  the  meaning  of  the  sev- 
eral sayings  such  as  "  The  early  bird  catches  the  worm." 

Such  ethical  questions  can  be  asked  as  What  would  you  do  if 
you  saw  a  man  drop  a  $io  bill  ? 

In  addition  to  the  tests  given  in  the  table  we  frequently  use  the 
Ebbinghaus  test  which  consists  of  having  the  patient  complete  a 
sentence  in  which  certain  words  have  been  left  out,  such  as:  I 
got  up  in  the  .  .  .  ,  and  after  washing  my  .  .  ,  went  to  .  .  .  Or 
better  often  is  Ziehen's  modification  of  this  test.  The  patient  is 
asked  to  complete  such  a  sentence  as  this  :  If  it  rains  .  .  .  because 
...  in  spite  of  .  .  .  The  Bourdon  test  is  very  valuable  as  a 
measure  of  attention.  It  consists  of  getting  the  patient  to  strike 
out  certain  recurring  letters  or  numbers  in  a  standard  page  and 
timing  the  result.  A  similar  test  is  the  tapping  test — timing  the 
number  of  taps  that  can  be  made  in  a  given  time,  say  thirty 
seconds. 

Of  course  the  cases  will  be  numerous  in  which  it  will  be  found 
desirable  or  necessary  to  pursue  the  examination  further  in  some 
direction.  No  scheme  can  cover  all  possibilities  and  would  be 
useless  if  it  did,  because  impossible  to  carry  out.  A^uch  must  of 
necessity  be  left  to  the  judgment  of  the  examiner.  By  following 
this  plan,  however,  it  is  beheved  that  the  general  and  important 
feature  necessary  for  a  case  record  will  be  covered  in  the  large 
majority  of  cases. 

It  is  useful,  after  completing  the  examination,  to  accent  the 
significant  features  in  a  short  summary,  which  might  include  a 
provisional  diagnosis  if  the  facts  warranted. 


CHAPTER  XXI. 

The  Binet-Simon  Scale. 

The  object  of  the  Binet-Simon  tests  is  to  determine  the  psycho- 
logical age  of  the  child.  Their  use  has  produced  already  a  large 
and  critical  literature.  No  attempt  will  be  made  here  to  discuss 
the  merits  of  the  many  questions  that  have  been  raised.  The 
important  point  is  that  this  scale,  in  skilled  hands,  is  a  most  effi- 
cient means  for  determining  the  mental  development  of  the  child. 
The  tests  will  be  given  as  modified  to  suit  American  children  by 
GoDDARD,  who  has  probably  had  more  extensive  experience  in  its 
use  than  anyone  else  in  this  country. 

All  the  questions  under  an  age  must  be  answered  to  pass  that  age. 

The  tests  are  as  follows: 

CHILDREN  OF  THREE  YEARS. 

1.  Where  is  Your  Nose?    Your  Eyes?    Your  Mouth? 

One  of  the  best  signs  of  awakening  intelligence  in  young  chil- 
dren is  the  comprehension  of  spoken  words.  We  test  this  by  ask- 
ing these  questions  which  can  be  answered  by  a  gesture. 

2.  Repetition  of  Sentences  of  Six  Syllables. 
It  rains.    I  am  hungry  (6  syllables). 

Experiment  proves  that  it  is  easier  for  a  child  to  repeat  words 
than  to  speak  a  word  of  his  own.  If  a  child  does  not  respond  one 
way  try  him  with  two  syllables  {" mama") ,  then  four,  etc. 

A  child  of  three  repeats  six  syllables  but  not  ten.  There  must 
not  be  a  single  error. 

3.  Repetition  of  Figures  "7,  2." 

A  child  of  three  can  repeat  two  figures.  Figures  require  closer 
attention  than  words  because  they  mean  nothing  to  him.  Pro- 
nounce the  figures  distinctly,  one-half  second  apart  and  without 
emphasis  on  any  one  figure. 

4.  Describing  Pictures. 

A  picture  is  shown  to  the  child  with  the  question,  "  What  do  you 

324 


THE  BINET-SIMON   SCALE.  325 

see?"  The  pictures  must  be  chosen  with  some  care.  Each  one 
must  represent  some  people  and  a  situation.  Binet  uses  three  pic- 
tures. The  first  is  a  man  and  a  boy  drawing  a  cart  loaded  with 
furniture.  The  second,  a  woman  and  an  old  man  sitting  on  a 
bench  in  a  park  in  winter.  The  third,  a  man  in  prison  looking  out 
of  the  window ;  a  couch,  chair  and  tables. 

A  child  of  three  names  the  things — enumerates.  He  does  not 
describe  any  actions  in  the  pictures. 

5.  Names  of  the  Family. 

All  children  of  three  know  their  first  names.  They  sometimes 
know  the  family  name  but  not  always. 

CHILDREN  OF  FOUR  YEARS. 

1.  Sex  of  Child.    Are  you  a  little  boy  or  a  little  girl? 
Children  of  three  do  not  know.     Children  of  four  always  do. 

2.  Naming  Familiar  Objects. 

One  takes  from  his  pocket  a  key,  a  knife,  and  a  penny. 

The  answers  should  indicate  that  the  child  knows  what  each  is. 
This  is  a  more  difficult  use  of  languge  than  naming  objects  in  the 
picture  because  there  the  child  chose  his  own  object  to  name;  here 
we  say,  "What  is  that  thing?" 

3.  Repetition  OF  Three  Figures.    "7,4,8." 

4.  Comparison  of  Two  Lines.    "Which  is  the  longer  line?" 
Draw  two  parallel  lines  three  centimeters  apart,  the  one  5  centi- 
meters and  the  other  6.     Hesitation  is  failure. 

CHILDREN  OF  FIVE  YEARS. 

1.  Comparison  of  Two  Weights.    "Which  is  the  heavier?" 
Use  weighted  blocks  of  wood  of  equal  size  and  appearance. 
Compare  3  grammes  with  12  grammes  and  6  grammes  with  15 

grammes.     Note  the  curious  and  interesting  errors  that  are  made. 

2.  Copying  a  Square. 

Draw  a  ^juare  of  3  or  4  centimeters.  Have  child  copy  it  with 
ink — not  pencil.  Pen  makes  it  harder.  It  is  satisfactory  if  one 
can  recognize  the  square. 

3.  Repeat:  His  name  is  John.    He  is  a  very  good  boy. 


326  outlines  of  psychiatry. 

4.  Counting  Four  Pennies. 

Place  four  pennies  in  a  row.  Insist  that  child  count  them  with 
his  finger. 

At  three  years  a  child  does  not  know  how  to  count  four :  at  four 
half  succeed :  at  five  all  succeed. 

5.  Game  of  Patience  With  Two  Pieces. 

Cut  a  visiting  card  diagonally.  Place  a  whole  card  on  the  table. 
Nearer  the  child  place  the  two  pieces  with  the  two  hypotenuses 
away  from  each  other.  Ask  the  child  to  make  a  figure  like  the 
uncut  card.     One  child  in  twelve  fails. 

Be  careful  (i)  that  child  does  not  fail  because  he  is  too  indolent 
to  reach  out  and  try ;  (2)  that  one  of  the  pieces  does  not  get  turned 
over — because  then  it  is  impossible;  (3)  that  you  do  not  show  by 
a  look  whether  the  child  is  right  or  wrong. 

CHILDREN  OF  SIX  YEARS. 

1.  Distinction  Between  Morning  and  Afternoon.    "Is  this 

morning  or  is  it  afternoon  f" 
It  should  be  remembered  that  a  certain  type  of  child  will  always 
answer  the  last  of  two  alternatives.     Therefore  if  the  time  is 
afternoon  it  is  well  to  put  the  question,  "Is  this  afternoon  or 
morning f"     Not  before  six  do  children  know  this. 

2.  Definition  of  Known  Objects.    "■  What  is  a  fork?  a  table f 

a  chair?  a  horse?  a  mama?" 

There  are  three  kinds  of  response,  (i)  Silence,  simple  repeti- 
tion or  gesture;  e.  g.,  "A  fork  is  a  fork,"  or  pointing  says,  "  That 
is  a  chair."  (3)  Definition  in  terms  of  use,  "A  fork  is  to  eat 
zvith."  (3)  Definitions  better  than  by  use.  This  includes  all  an- 
swers that  describe  the  thing  or  even  begin  with  "  it  is  a  thing  " — 
"it  is  an  animal,"  etc.,  all  of  which  expressions  are  not  so  child- 
like as  the  simple  "use"  definitions.  In  deciding  which  type  of 
answer  we  shall  credit  to  the  child,  we  accept  three  out  of  five. 

At  four  years  half  the  children  define  by  " use" ;  it  increases  a 
little  at  five  and  at  six  practically  all  define  this  way.  Not  before 
nine  do  the  majority  give  the  definitions  that  are  "better  than 
by  use." 

3.  Execution  of  Three  Simultaneous  Commissions. 

"Do  you  see  this  key?    Put  it  on  that  chair.     Then  shut  the 


THE  BINET-SIMON   SCALE. 


327 


Fig.  5.    BiNET  Test  Age  VI.    No.  5. 


328  OUTLINES   OF    PSYCHIATRY. 

door.  After  that  bring  me  the  box  that  is  on  the  chair.  Remem- 
ber, first  the  key  on  the  chair,  then  close  the  door,  then  bring  in 
the  box.    Do  you  understand?    Well,  then,  go  ahead." 

Such  are  the  directions.  They  must  all  be  done  without  further 
help,  hint  or  suggestion.  At  four  years  almost  none  can  do  this ; 
at  five  about  half,  at  six  all,  or  nearly  all,  succeed. 

4.  Right  Hand.    Left  Ear. 

One  says  to  child,  "  Show  me  your  right  hand,"  and  when  that 
is  done,  "  Show  me  your  left  ear."  There  are,  in  the  main,  three 
kinds  of  response,  (i)  Does  not  know  right  and  left.  Shows 
right  hand  because  of  natural  tendency.  Shows  right  ear  also. 
(2)  Knows  but  is  not  sure.  Shows  right  hand,  then  right  ear, 
but  corrects  himself  at  once.  (3)  Knows  and  without  hesitation 
touches  right  hand  and  left  ear.  (2)  and  (3)  are  considered  satis- 
factory. If  child  touches  one  hand  with  the  other  in  such  a  way 
that  one  cannot  tell  which  hand  he  means,  ask  him  to  hold  his 
right  hand  up  high.  Be  very  careful  in  this  test  to  give  no  hint 
by  look  or  word.  At  four  years  no  child  points  to  left  ear;  at 
five  half  of  the  children  make  a  mistake ;  at  six  all  succeed. 

5.  Esthetic  Comparison. 
"Which  is  the  prettier?" 

Binet  uses  six  heads  of  women  in  three  pairs,  the  one  pretty 
and  the  other  ugly  or  even  deformed,  Fig.  5.  Care  is  taken  that 
the  pretty  one  is  now  at  the  left  and  now  at  the  right.  At  six  all 
choose  correctly;,  at  five  about  half. 

CHILDREN  OF  SEVEN  YEARS. 

1.  Counting  Thirteen  Pennies. 

Pennies  must  be  placed  in  a  row  and  counted  with  the  finger. 
Finger  must  touch  the  piece  at  the  same  time  that  the  child  names 
the  number.  No  piece  must  be  counted  twice  and  none  omitted. 
The  number  thirteen  must  be  given  exact.  At  six  years  two 
thirds  fail;  at  seven  they  make  no  errors. 

2.  Description  of  a  Picture. 

Same  picture  as  used  in  age  three.  Child  now  describes  things 
instead  of  simply  enumerating. 

3.  Unfinished  Pictures. 

One  shows  four  sketches  of  such  as  Fig.  6.     Ask  the  child, 


THE   BINET-SIMON    SCALE.  329 

"  What  is  lacking  in  that  picture?  "  Child  must  answer  three  out 
of  four  correctly.  At  five  years  none  are  correct;  at  six  errors 
number  two  thirds;  at  seven  the  great  majority  are  accurate. 

4.  Copying  a  Diamond. 

Draw  a  rhombus  about  the  size  of  the  square  used  for  age  five. 
Have  child  copy  this  with  pen.  The  result  is  satisfactory  if  it 
would  be  recognized  as  intended  for  a  diamond  shaped  figure. 

5.  Name  Four  Colors. 

Use  red,  blue,  green  and  yellow  papers,  in  pieces  about  1x3 
inches.  Touching  each  color  with  the  finger  ask,  "  What  is  that 
color f"  It  will  be  seen  this  is  a  test  of  color  names,  not  of  dis- 
crimination.    It  should  be  done  in  six  seconds. 

CHILDREN  OF  EIGHT  YEARS. 

1.  Compare  Two  Things  From  Memory. 

"What  is  the  difference  between  a  butterfly  and  a  fly?" 
"  Wood  and  glass?"     "Paper  and  pasteboard  {or  cloth)?" 

The  question  may  be  differently  put  so  as  to  make  it  intelligible 
as  possible;  e.  g.,  "Why  are  they  not  alike?"  etc. 

Two  at  least  out  of  the  three  pairs  should  be  answered  cor- 
rectly.    If  it  takes  more  than  two  minutes  it  is  a  failure. 

At  six  a  third  of  the  children  do  this  test ;  at  seven  nearly  all ; 
at  eight  all. 

2.  Count  Backwards  From  20  to  i. 

This  should  be  done  within  twenty  seconds,  and  only  one  mis- 
take allowed  of  omission  or  transposition. 

3.  The  Days  of  the  Week. 

These  must  be  given  in  order  without  omission  within  ten 
seconds. 

4.  Count  Nine  "Sous"  (3  Simples  and  3  Doubles). 

(Our  two-cent  piece  is  now  so  rare  that  we  use  one-cent  and 
two  cent  postage  stamps.)  Arrange  in  order,  i,  i,  i,  2,  2,  2. 
"How  much  are  they  worth?"  {"How  much  money  to  buy 
them?")     "Count." 

It  should  be  done  within  ten  seconds  without  any  error.  There 
are  three  ways  of  counting.  One  child  says  i,  2,  3,  5,  7,  9. 
Another  says  i,  2,  3,  4-5,  6-7,  8-9.    The  third  says  i,  2,  3,  4,  5,  6, 


330 


OUTLINES  OF   PSYCHIATRY. 


Fig.  6.    Binet  Test  Age  VII.    No.  3. 


THE   BINET-SIMON   SCALE.  33  I 

which  is  of  course  wrong.     A  large  majority  do  this  test  at  seven 
years.     But  all  do  it  at  eight. 

5.  Repetition  of  Five  Figures.    "4-7-3-9-5." 

Same  method  of  procedure  as  given  above,  age  three.  Only 
three  fourths  of  the  children  succeed. 

CHILDREN  OF  NINE  YEARS. 

1.  Make  Change — 4  Cents  Out  of  20. 
Play  store,  using  real  money. 

If  child's  cash  consists  of  20  pennies,  4  nickels,  and  2  dimes, 
interesting  degrees  of  intelligence  will  be  discovered  by  noticing 
the  coins  he  uses  in  making  change.  Child  is  storekeeper.  One 
buys  something  that  costs  9  cents.  Child  must  actually  give  16 
cents  as  well  as  say  it. 

At  seven  no  one  can  do  this  test ;  at  eight  a  good  third  succeed ; 
at  nine  all  do  it. 

2.  Definition  Better  than  by  "Use." 

This  was  explained  under  age  six.  Accept  any  definition  that 
is  more  than  simply  "  use,"  e.  g.,  chair  has  four  legs,  table  is  made 
of  wood,  etc.  At  ages  seven  and  eight,  half  the  children  give 
definitions  of  this  kind;  at  nine  they  all  do. 

3.  Name  the  Day  of  the  Week,  the  Month,  the  Day  of  the 

Month  and  the  Year. 
The  test  is  passed  even  if  the  day  of  the  month  is  as  much  as 
three  days  wrong.     Children  least  often  know  the  year. 

4.  The  Months  of  the  Year. 

Recited  in  order  within  fifteen  seconds.  Allow  one  omission  or 
transposition. 

5.  Arrangement  of  Weights. 

Use  five  wooden  cubes  of  same  size  and  appearance  but  loaded 
so  as  to  weigh  6,  9,  12,  15,  18  grammes.  (Metal  pill  boxes  may 
be  used.)  Place  the  five  boxes  on  table  in  front  of  child  and  ex- 
plain that  they  do  not  all  weigh  alike  and  he  is  to  lift  one  at  a  time 
and  put  them  in  order  from  the  lightest  to  the  heaviest.  (The 
initial  of  each  weight  written  on  the  bottom  of  each  box  makes  it 
easy  to  see  if  they  are  right.)  Record  the  exact  order  in  which 
the  child  has  placed  them.     Three  trials  are  made.     Two  must  be 


332  OUTLINES   OF   PSYCHIATRY. 

absolutely  correct.     The  whole  operation  must  not  take  over  three 

minutes. 

CHILDREN  OF  TEN  YEARS. 

1.  Naming  Nine  Pieces  of  Money. 

One  may  use  cent,  nickel,  dime,  quarter,  half  dollar,  dollar, 
two  dollars,  five  dollars,  and  ten  dollars. 

Pieces  should  be  on  table  in  a  row  but  not  in  regular  order  of 
value.     Point  with  finger,  and  name  as  he  points. 

2,  Copy  Design. 


H^UB- 


Expose  ten  seconds. 

3.  Repeats  Six  Figures. 
854726,  274681,  941738. 

4.  Questions  of  Comprehension,    First  Series. 
What  ought  one  to  do 

1.  When  one  has  missed  the  train? 

2.  When  one  has  been  struck  by  a  playmate  who  did  not  do  it 
purposely  ? 

3.  When  one  has  broken  something  that  does  not  belong  to 
one? 

At  seven  and  eight  half  respond  correctly;  at  nine  three 
fourths ;  at  ten  all.  If  two  questions  out  of  three  are  answered 
correctly  the  test  is  passed. 

Second  Series. 
What  ought  one  to  do 

1.  When  he  is  detained  so  that  he  will  be  late  for  school? 

2.  What  ought  one  to  do  before  taking  part  in  an  important 
affair  ? 

3.  Why  does  one  excuse  a  wrong  act  committed  in  anger  more 
easily  than  a  wrong  act  committed  without  anger  ? 

4.  What  should  one  do  when  asked  his  opinion  of  some  one 
whom  he  knows  only  a  little  ? 


THE  BINET-SIMON   SCALE.  333 

5.  Why  ought  one  to  judge  a  person  more  by  his  acts  than 
by  his  words? 

Allow  at  least  20  seconds  to  each  question.  Three  of  the  five 
must  be  answered  correctly.  At  seven  and  eight  no  one  responds 
to  a  majority  of  his  second  series;  at  ten  half  are  successful;  it 
is  therefore  a  transition  between  ten  and  eleven  years. 

5.  Using  Three  Words  in  a  Sentence. 

Binet  uses  the  words  Paris,  fortune,  river.  We  should  say 
Philadelphia,  money,  river.  This  is  the  first  time  in  these  tests 
that  we  have  required  the  child  to  "  invent "  his  own  expression. 
There  are  three  forms  of  answers.  ( i)  Three  separate  sentences. 
(2)  Two  ideas  united  by  a  conjunction.  (3)  A  single  idea  in- 
volving the  three  words.  Only  the  last  two  are  satisfactory  for 
the  test.  We  allow  one  minute.  At  eight  no  one  succeeds.  At 
nine  one  third  and  at  ten  one  half  get  it  right. 

In  this  test  may  be  seen  a  distinction  between  intelligence  and 
judgment.  Some  children  give  a  complete  sentence  with  the  three 
words  but  they  do  not  make  sense. 

CHILDREN  OF  ELEVEN  YEARS. 
I.  Criticism  of  Sentences. 

These  are  sentences  that  contain  some  absurdity  or  ridiculous 
expression.  Binet  explains  that  formerly  he  used  sentences  like 
"Is  snow  red  or  black f"  but  he  found  that  many  bright  children 
fell  into  the  trap  and  others  through  confidence  in  the  questioner 
failed  to  look  for  an  absurdity.  Therefore  he  has  changed  the 
plan  and  now  says  to  the  child,  '"/  am  going  to  give  you  some 
sentences  in  which  there  is  nonsense.  You  listen  carefully  and 
see  if  you  can  tell  me  where  the  nonsense  is."  Then  he  reads  the 
sentence  very  slowly. 

These  are  the  sentences: 

1.  An  unfortunate  cyclist  has  had  his  head  broken  and  is  dead 
from  the  fall:  they  have  taken  him  to  the  hospital  and  they  do 
not  think  that  he  will  recover. 

2.  /  have  three  brothers,  Paul,  Ernest  and  myself. 

3.  The  police  found  yesterday  the  body  of  a  young  girl  cut  into 
eighteen  pieces.     They  believe  that  she  killed  herself. 

4.  Yesterday  there  was  an  accident  on  the  railroad.  But  it  was 
not  serious:  the  number  of  deaths  is  only  48. 


334  OUTLINES  OP  PSYCHIATRY. 

5.  Some  one  said  "If  in  a  moment  of  despair  I  should  commit 
suicide,  I  should  not  choose  Friday,  because  Friday  is  an  unlucky 
day  and  it  would  bring  me  ill  luck." 

The  test  should  last  about  two  minutes.  Three  at  least  of  the 
questions  should  receive  good  answers.  At  nine  years  hardly  any 
child  gets  them ;  at  ten  scarcely  a  fourth ;  at  eleven  a  half. 

2.  Three  Words  in  a  Sentence.     (Given  under  age  ten.) 
At  eleven  all  succeed. 

3.  60  Words  in  3  Minutes. 

"'  Say  as  many  words  as  you  can  in  5  minutes;  as  table,  board, 
beard,  shirt,  carriage."  We  tell  him  that  some  children  have 
named  200  words. 

This  test  gives  a  splendid  opportunity  to  appreciate  the  intelli- 
gence of  a  child.    At  least  60  words  must  be  given. 

4.  Rhymes. 

Explain  what  is  meant  by  one  word  rhyming  with  another. 
Illustrate.  Then  ask  for  as  many  words  as  the  child  can  think  of, 
that  rhyme  with  a  given  word,  e.  g.,  day  or  spring  or  mt//. 

One  minute  is  allowed.  Three  rhymes  with  one  word  should 
be  found  in  the  given  time. 

5.  Words  to  Put  in  Order. 

"Make  a  sentence  out  of  these  words." 

Hour — for — we — good — at — park — a — started — the. 

To — asked — exercise — my — have — teacher — correct — my — I. 

A — defends — dog — ^good — his — courageously — ^master. 

Place  the  printed  words  before  the  child.  He  gives  the  sen- 
tence orally. 

Time  limit  is  one  minute  for  each  sentence.  At  least  two  must 
be  given  correctly. 

CHILDREN  OF  TWELVE  YEARS. 

1.  Repetition  of  Seven  Figures.    2,  9,  4,  6,  3,  7,  5.     i,  6,  9, 

5,  8,  4,  7.    9,  2,  8,  5,  I,  6,  4. 
Tell  the  child  there  will  be  seven  figures.     Give  three  trials. 
One  success  is  sufficient. 

2.  Abstract  Definitions. 

"What  is  charity?  justice?  goodness?" 


THE  BINET-SIMON   SCALE.  335 

Two  good  definitions  must  be  given.  It  is  often  somewhat 
difficult  to  decide  if  the  definition  is  passable.  If  it  contains  the 
essential  idea  it  must  be  accepted  however  badly  it  is  expressed. 
At  ten  years  a  third  succeed;  at  eleven  they  are  generally  suc- 
cessful. 

3.  Repeats. 

/  saw  in  the  street  a  pretty  little  dog.  He  had  curly  hair,  short 
legs  and  a  long  tail. 

4.  Resists  Suggestion. 

Binet's  description  of  this  test  is  as  follows : 

Prepare  a  little  booklet  of  six  pages.  On  first  page  draw  in  ink 
two  lines  horizontal:  the  one  to  the  left  two  inches  (4  cm.)  long, 
the  one  to  the  right  two  and  a  half  inches.  On  second  page,  left 
line  is  two  and  a  half,  right,  three  inches.  Third  page,  left  line 
three  and  right  one  three  and  a  half  inches.  On  three  remaining 
pages  all  lines  are  three  and  a  half  inchs  long.  The  lines  on 
each  page  are  in  same  straight  line  and  separated  by  a  half  inch. 

The  idea  of  the  test  is  this :  Child  having  said  the  right-hand 
one  is  longer  for  three  times,  will  he  continue  even  when  he 
comes  to  those  that  are  alike,  or  will  he  "resist  the  suggestion" 
and  say  they  are  alike? 

Care  must  be  exercised  in  asking  the  question.  For  the  first 
two  pages  ask  "Which  is  the  longer  line?  "  but  for  the  others  say 
merely,  "And  there?" 

5.  Problem  of  Various  Facts.     {What  is  it?) 

"A  person  who  was  walking  in  the  forest  at  Fontainebleau 
suddenly  stopped  much  frightened  and  hastened  to  the  nearest 
police  and  reported  that  he  had  seen  hanging  from  the  limb  of  a 
tree  a '  (after  a  pause)  "what?" 

(2)  "My  neighbor  has  been  having  strange  msitors.  He  has 
received  one  after  the  other  a  physician,  a  lawyer  and  a  clergy- 
man.    What  has  happened  at  the  house  of  my  neighbor?" 

Both  questions  should  be  answered  correctly. 

The  answer  to  the  first  is  "a  dead  man."  Some  object  to  this 
story  as  too  gruesome.  Others  say  that  children  are  not  so  sensi- 
tive to  such  things  as  we  think.  Aside  from  that  question  it 
would  seem  that  the  picture  is  hardly  familiar  enough  in  America 
to  make  the  answer  certain.     A  substitute  better  be  found. 


336 


OUTLINES   OF   PSYCHIATRY. 


CHILDREN  OF  FIFTEEN  YEARS. 

1.  Interprets  Picture. 

I.  Use  same  pictures  as  in  age  three,  test  four,  and  age  seven, 
test  two.  The  test  is  credited  in  XV  if  subject  "interprets"  the 
feeling  of  the  picture — usually  expressed  by  some  word  of  sym- 
pathy, fear,  sorrow,  joy  or  other  feeling. 

2.  Change  Hands  of  Clock. 

Interchange  the  hands  of  a  clock  for  (i)  the  hour  6:20  and  (2) 
2:56.  (Child  must  not  see  a  watch  or  clock.  It  is  a  test  of 
imaging  power.) 

3.  Code.     Come  quickly. 

This  test  was  suggested  by  Dr.  William  Healy,  of  Chicago. 
It  was  used  by  the  Southern  army  in  the  Civil  War. 

The  diagrams  shown  below  are  to  be  constructed  while  the 
child  gives  close  attention.  He  notes  the  arrangement  of  the 
letters,  in  alphabetical  order  vertically  in  first  and  second,  and 
counter-clockwise  in  a  third  and  fourth  dirgram.  Two  and  four 
differ  from  one  and  three  in  having  a  dot  in  each  section.  Once 
knowing  the  scheme,  the  letters  may  be  left  out  and  a  cipher  dis- 
patch written  by  using  for  each  letter  the  part  of  the  diagram  in 
which  the  letter  is  placed  in  the  key.  For  example  "  war  "  would 
be  written    ^ |  p^ 

Having  made  it  perfectly  clear,  remove  the  key  and  have  child 
write  on  back  of  record  sheet,  "  Caught  a  spy,"  in  this  code.  In 
crediting  allow  one  error.  Every  wrong  or  incomplete  symbol 
is  an  error. 


A 

D 

G 

B 

E 

H 

C 

F 

I 

J 


K 


N 


p 


Q 
r" 


4.  Opposites. 

Ask  child  to  write  the  opposites  of  the  following  words:  (i) 
good;  (2)  outside;  (3)  quick;  (4)  tall;  (5)  big;  (6)  loud;  (7) 
white;  (8)  light;  (9)  happy;  (10)  false;  (11)  like;  (12)  rich; 


THE   BINET-SIMON    SCALE.  337 

(13)  sick;  (14)  glad;  (15)  thin;  (16)  empty;  (17)  war;  (18) 
many;  (19)  above;  (20)  friend. 

Besides  the  obvious  answers,  the  following  are  accepted  as 
right  or  half  right : 

(2)  in  or  indoors  (half)  ;  (3)  lazy  or  slowly  (half)  ;  (4)  little 
or  low  (half)  ;  (5)  short  (half)  ;  (6)  soft  or  low  (right),  whisper 
(half)  ;  (9)  sorry  or  sorrow  (half)  ;  (10)  right  or  truth  (half)  ; 
(11)  dislike,  unlike  or  hate  (right)  ;  (13)  healthy  (right)  ;  (14) 
mad  (right);  (15)  broad  (half);  (16)  filled  (right);  (18)  none 
(right);  (19)  under  (right). 

It  is  best  to  have  the  words  printed  on  a  slip  of  paper  in  vertical 
column,  with  space  for  child  to  write  the  "  opposite  "  at  the  right. 

The  equivalent  of  17  correct  answers  must  be  given. 

ADULT.i 

1.  Cutting  Out. 

Get  the  child's  attention  and  let  him  see  you  fold  a  sheet  of 
paper  in  four.  Then  with  the  scissors  cut  a  small  triangle  from 
one  edge — the  edge  which  does  not  open.  Ask  him  to  draw  a 
picture  of  the  paper  as  it  will  look  when  unfolded.  Do  not  un- 
fold or  allow  another  sheet  to  be  folded.  It  is  a  difficult  test. 
If  a  child  does  it  the  first  time  always  ask  him  if  he  has  seen  it 
before. 

2.  The  Reversed  Triangle. 

Cut  a  visiting  card  along  the  diagonal.  Ask  child  to  describe 
the  resulting  shape  if  one  of  the  triangles  was  turned  about  and 
placed  so  that  its  short  leg  was  on  the  other  hypothenuse  and  its 
right  angle  at  the  smaller  of  the  two  acute  angles. 

3.  Differences. 

Ask  the  difference  between 

Pleasure  and  honor. 

Evolution  and  revolution. 

Event  and  advent. 

Poverty  and  misery. 

Pride  and  pretention. 
4.  Say  to  the  subject :  "  There  are  three  differences  between 
the  President  of  a  Republic  and  a  King.     What  are  they  ? " 

1  Adult  is  used  here  in  the  sense  of  over  fifteen  years  of  age. 


338  OUTLINES   OF   PSYCHIATRY. 

The  answer  should  contain  the  three  ideas,  Royalty  is  (i) 
hereditary,  (2)  lasts  for  life,  and  (3)  the  monarch  has  extended 
powers.  The  President  is  (i)  elected,  (2)  for  a  definite  time, 
and  (3)  his  powers  are  usually  less  extensive  than  those  of  a 
king. 

5.  Give  Sense  of  a  Selection  Read. 

Explain  to  the  subject  that  you  are  about  to  read  a  selection  to 
him,  and  that  then  you  will  ask  him  to  tell  you  the  substance  of 
what  you  have  read.     He  should  give  close  attention. 

Read  slowly,  in  a  clear  voice  and  with  expression,  the  following : 

"  One  hears  very  different  judgments  on  the  value  of  life. 
Some  say  it  is  good,  others  say  it  is  bad.  It  would  be  more  cor- 
rect to  say  that  it  is  mediocre ;  because  on  the  one  hand  it  brings 
us  less  happiness  than  we  want,  while  on  the  other  hand  the  mis- 
fortunes it  brings  are  less  than  others  wish  for  us.  It  is  the 
mediocrity  of  life  that  makes  it  endurable;  or  still  more,  that 
keeps  it  from  being  positively  unjust." 

It  is  correct  if  the  subject  gives  the  central  thought  in  his  own 
words ;  e.  g.,  "  Life  is  neither  good  nor  bad,  but  mediocre,  be- 
cause it  is  inferior  to  what  we  wish  and  not  as  bad  as  others 
wish  for  us." 


INDEX. 


Actions,  4 
Affects,  5 
Akoasms,  56 
Alcoholic  epilepsy,  224 

hallucinosis,  225 
Alcoholism,  216 

chronic,  223 

course,  232 

pathology,  232 

psychology  of,  217 

treatment,  232 
Allopsychoses,  66 
AU-powerfulness  of  thought,  12 
Amnesia,  78 
Anger,  tj 
Anxiety,  Tj,  191 

hysteria,  269 

neurosis,  268 
Apoplectiform  seizures,  139 
Apoplexy,  247 
Apperception,  tests  for,  303 
Apprehension,  tests  for,  303 
Aprosexia,  78 

Argyll-Robertson  pupil,  134 
Arterio-sclerosis,  206 
Association,  clang,  72 

saltatory,  163 

tests,  310 
Astasia  abasia,  267 
Ataxia,  intrapsychic,  159 

noo-thymopsychic,   159 
Attention,  disorders  of,  78 

tests  of,  307 

voluntary,  160 
Auto-erotism,  11 
Automatism,  18,  'JT,  172 
Autopsychoses,  66 
Auto-toxic  psychoses,  250 

Bath,  continuous,  41 
Bestiality,  274 


Binet  Simon  scale,  324 

Catalepsy,  ^6,  172 
Catatonia,  170 
Catatonic  excitement,  172 

stupor,  171 
Causes  of  mental  disorder,  30 
Character,  study  of,  27 

epileptic,  242,  269 

hysterical,  269 

manic-depressive,  269 

neurasthenic,  269 

paranoiac,  89 

post-traumatic,  270 

psychasthenic,  270 

"  shut  in,"  158,  178,  187,  270 

unresistive,  270 
Chloral,  44 
Chloralamid,  44 
Chorea,  Huntington's,  252 

Sydenham's,  252 
Circumscribed  psychosis,  107 
Circumstantiality,  73 
Clang  association,  72 
in  mania,  119 
Classification  of  the  psychoses,  24, 28 

of  causes  of  mental  disorder,  30 
Cocainism,  236 
Complex,  31,  81 

dormant,  83 

submerged,  311 

determination  of,  311 
Compulsion,  75 

neurosis,  268 
Concepts,  classification  of,  66 

imperative,  70 
Conduct,  definition  of,  5 
Confabulation,  opportune,  228 

suggestion,  229 
Conflict,  9 
Confusion,  192 


339 


340 


INDEX. 


Confusion,  acute  hallucinatory,  213 

definition  of,  209 

primary,  214 

secondary,  214 

in  mania,  121 

senile,  200 
Consciousness,  clouding  of,  61 

double,  81 

threshold  of,  61 

wave  of,  62 
Constitutional  inferiority,  270 
Conversion,  83,  258 
Cranks,  270 
Cretinism,  251,  277 
Criminal,  270 
Cyclothymia,  125 

Decortication,  148 
Degenerates,  insanity  of,  100 
Degeneration,  stigmata  of,  no 
Delirium,  abstinence,  219 

collapse,  212 

definition  of,  209 

febrile,  211 

infection,  210 

of  interpretation,  loi 

of  negation,  80,  193 

occupation,  222 

of  revindication,  103 

senile,  201 

sine*delirio,  222 

tremens,  219 
febrile,  222 
Delusional  control,  191 
Delusions,  63 

changeable,  65 

endogenous,  65 

exogenous,  66 

of  explanation,  92,  193 

fixed,  64 

of  grandeur,  108,  193 

hypochondriacal,  193 

nihilistic,  193 

of  persecution,  92,  108,  193 

of  possession,  194 

of  poverty,  193 

retrospective  explanatory,  94 


Delusions  of  sin,  190,  193 
systematized,  65 
unsystematized,  65 
Dementia,  alcoholic,  204 
Dementia  praecox,  156 

general  characteristics,  156 
etiology,  156 

general  symptomatology,  158 
mental,  158 
physical,  164 
mode  of  onset,  164 
varieties,  165 

dementia  simplex,  165 
hebephrenia,  166 
catatonia,  170 
paranoid,  175 
mixed  states,  178 
course,  178 
progress,  178 
diagnosis,  180 
pathology,  182 
nature  of,  183 
treatment,  186 
prophylaxis,  187 
Depersonalization,  80 
Depression,  yj 

apprehensive,  190 
psychogenic,  270 
Deterioration,  senile,  200 
Diabetes,  250 
Dipsomania,  232,  267 
Disorientation,  6^ 
Displacement,  83,  268 
Distractibility,  72 
in  mania,  119 
Dotard,  199 
Doubts,  70 
Dreams,  83 
Dream  states,  62 

alcoholic,  231 
epileptic,  242 
hysterical,  260 
Drunkenness,  218 
pathological,  219 

Echolalia,  76,  172 
Echopraxia,  76,  172 


INDEX. 


341 


Emotion,  definition  of,  5 

disorders  of,  ^^ 
Emotional  depression   in   paranoia, 

91 

Emotional  deterioration,  ^^ 

in  dementia  precox,  161 

exaltation  in  mania,  120 
Epilepsy,  241 

alcoholic,  224 

arterio-sclerotic,  244 

diagnosis,  244 

early,  241 

late,  241 

nocturnal,  244 

pathology,  244 

psychic,  242 

sexual  characteristics  in,  243 

toxic,  244 

traumatic,  244 

syphilitic,  244 
Epileptic  automatism,  242 

character,  242 

dementia,  243 

dream  states,  242 

equivalent,  242 

furor,  242 

ill-humor,  243 

sexuality,  243 

voice,  244 
Epileptiform  seizures  in  paresis,  138 
Epochal  psychoses,  205 
Ethical  questions,  315 
Exaltation,  "jy 
Examination,  mental,  283,  296,  321 

neurological,  292,  320 

physical,  292,  320 

special,  298 

standard  minimum,  317 

of  stuporous  cases,  315 
Exhaustion  psychoses,  212 
Exhibitionism,  274 
Exophthalmic  goitre,  251 
Extroversion,  23 

Falsification,  retrospective,  94 

of  memory,  94,  228 
Febrile  psychoses,  210 


Feeble-mindedness,  275 
Feeling  of  unreality,  80,  193 
Feelings,  5 
Fetichism,  274 
Flexibilitas  cerea,  76,  172 
Flight  of  ideas,  71 

sensory,  222 
Food,  refusal  of,  42 
Furor,  epileptic,  242 

Ganser's  symptom,  81 
Gastro-intestinal  disease,  251 
Goal  idea,  71 
Grimaces,  171 

Hallucination,  53 

apperception,  54 

auditory,  56 

in  paranoia,  92 

in  depression,  123 

haptic,  57 

hypnagogic,  55 

in  mania,  120 

motor,  58 

organic,  58 

pseudo,  54 

psychic,  54 

reflex,  58 

of  smell,  57 

of  taste,  57 

visual,  57 
Heart  disease,  253 
Heredity,  31 

dissimilar,  34 

similar,  34 
History  of  family,  284,  318 

of  illness,  289,  319 

of  patient,  286,  319 
Homosexuality,  12,  274 
Hydrotherapy,  40 
Hyoscyamus,  44 
Hypermnesia,  78 
Hyperprosexia,  79 
Hypochondriacal    ideas    in    depres- 
sion, 122 
in  paranoia,  91 
in  paresis,  141 


342 


INDEX. 


Hysteria,  257 

degenerative,  262 
Hysterical  psychosis,  262 

Ideas,  autochthonous,  70 
Ideas,  definition  of,  4 

fixed,  69 

fligh  of,  71 

goal,  71 

of  grandeur,  194 

hyperquantivalent,  dj 

imperative,  70 

nihilistic,  194 

of  insignificance,  194 

of  reference,  91 
retrospective,  94 

leveling  of,  in  mania,  119 

poverty  of,  168 

of  self-importance  in  paranoia, 
93 

of  unworthiness,  193 
Idiocy  and  imbecility,  275 

causes,  276 

general  considerations,  276 

course,  279 

prognosis,  279 

treatment,  280 
Idiocy,  276 

amaurotic  family,  277 

epileptic,  278 

hydrocephalic,  277 

inflammatory,  278 

microcephalic,  277 

mongolism,  279 

paralytic,  278 

sclerotic,  278 

sensorial,  278 

syphilitic,  279 

thyroigenous,  277 

traumatic,  278 
Idio-imbecility,  276 
Idiots-savants,  279 
Idiots,  apathetic,  277 

excitable,  277 

rhythmic,  277 
Illusions,  S3 
Imbecility,  275 


Imbecility,  moral,  275 
Impulsion,  74 
Infantalism,  279 

Infection-exhaustion  psychoses,  209 
course,  213 
diagnosis,  213 
Infection-exhaustion  treatment,  214 
Insanity,  concept  of,  26,  30 

of  degenerates,  100 
Insomnia,  treatment  of,  44 
Intellect,  2 

Intoxicants,  miscellaneous,  237 
Introversion,  22 
Involution  melancholia,  189 
etiology,  189 
symptomatology,  190 

melancholia  vera,   192 
anxietas  prasenilis,  192 
depressio       apathetica, 

193 
course,  194 
prognosis,   194 
termination,   194 
pathology,  195 
interpretation    of    the    psy- 
chosis, 195 
treatment,  195 
differential   diagnosis,    196 

Judgment,  definition  of,  4 

Korsakow's  psychosis,  228 
S3mdrome  in  paresis,  141 
in  senility,  200,  203 

Lactational  psychoses,  206 
Liar,  pathological,  270 
Libido,  10 

nutritive,  10 

sexual,  10 
Livingston's  solution,  233 

Mania,  acute  delirious,  121 
Mania,  chronic,  121 
Manias,  74,  267 

Manic-depressive  psychoses,  112 
etiology,  112 


INDEX. 


343 


Manic-depressive  psychoses,  general 
symptomatology,    113 
hypomania,  117 
acute  mania,  119 
delirious  mania,  120 
simple  retardation,  121 
acute  melancholia,  122 
depressive  stupor,   123 
maniacal  stupor,  126 
agitated  depression,  126 
unproductive  mania,  126 
depressive  mania,  126 
depression    with    flight 

of  ideas,  126 
akinetic  mania,  126 
interpretation   of   the   psy- 
chosis, 127 
course,  128 
prognosis,  128 
differential  diagnosis,  129 
pathology,  130 
treatment,  130 
prophylaxis,  131 
Mannerisms,  75,  174 
Masochism,  273 
Masturbation,  273 
Melancholia,  agitated,  191 
involution,  189 

interpretation  of,  195 
Memory,  definition  of,  5 
in  dementia  precox,  162 
disorders  of,  78 
falsification  of,  78 
tests  of,  308 
Mental  disorder,  causes  of,  29 
classification  of,  24,  28 
as  type  of  reaction,  16 
Mood,  definition  of,  6 
Moron,  276 
Motorium,  2 
Multiple  sclerosis,  252 
Muscular  tension,  171 
Mutism,  171 
Myxedema,  251 

Narcissism,  12,  274 
Necrophilia,  274 


Negativism,  76 

in  dementia  precox,  171 
Neurasthenia,  255 
Nihilistic  delusions,  193 

ideas,  194 

Observations,  general,  291,  319 
Obsessions,  69,  266 

emotional,  266 

volitional,  267 

intellectual,  267 

aboulic,  267 
Opiumism,  234 
Orientation,  63 

Paralexia,  222 
Paraldehyde,  44 
Paralysis  agitans,  252 

of  thought,  74 
Paralytic  dementia,  137 

psychosis,  137 
Paramnesia,  78 
Paranoia,  87 

description  of,  87 

interpretation  of,  108 

of  Magnan,  91 

of  Krafft-Ebing,  96 

of  Kraepelin,  100 

of  Freud,  108 

of  Serieux  and  Capgras,  loi 

varieties : 

hallucinatoria,  96 

combinatoria,  96 

early  or  original,  96 

late  or  acquired,  96 

querulous  or  litigous,  97 

persucatory,  97 

expansive,  97 

inventive,  97 

reformatory,  97 

religious,  97 

erotic,  97 

secondary,  108 

acute,  106 
course,  109 
prognosis,  109 
differential  diagnosis,  109 


344 


INDEX. 


Paranoia,  pathology,  no 

treatment,  no 
Paranoid  states,  io6 
Paraphasia,  222 
Paraphrenia,  100,  176 
Paresis,  132 

etiology,  132 

general  characterization,   132 
general  considerations.  132 
types : 

tabetic,  138 
Lissauer's,  138 
galloping,  140 
demented,   140 
excited,  140 
agitated,  140 
depressed,  141 
juvenile,  147 
gross  pathology,  148 
histopathology,  148 
interpretation    of    paretic    psy- 
chosis, 150 
diagnosis,  151 
course,  154 
prognosis,  154 
treatment,  155 
Paretic  seizures,  138 
Passion,  definition  of,  6 
Pellagra,  252 
Perception,  2 

definition  of,  4 
disorders  of,  S3 
Perseveration,  76,  173 
Personality,  in  depression,  122 
disorders  of,  79 
multiple,  80 

transformation  of,  80,  94 
Phantasy,  9 
Phobias,  70,  266 
Phonemes,  56 
Photomata,  57 
Pithiatism,  258 
Plasma  cells,  149 
Pleasure-pain  motive,  9 
Polioencephalitis,    acute    hemor- 
rhagic, 230 
Polyneuritis,  252 


Post-febrile  psychoses,  211 
Pre-febrile  psychoses,  210 
Presbyophrenia,  200,  203 
Pre-senile  dementia,  199 
Pressure  of  activit}%  120 
Prophylaxis,  51 
Pseudologia  phantastica,  270 
Pseudo-paranoia,  alcoholic,  227 
Pseudo-paresis,  alcoholic,  224 

syphilitic,  246 
Pseudo-reminiscences,  229 
Pseudo-stupor,  77 
Psychasthenia,  264 
Psyche,  splitting  of,  160 

fragmentation  of,  184 
Psychoanalysis,  45 
Psychomotor  activity,  74 
decreased,  74 
increased,  74 
Psychoneuroses,  255 
Psychopathic  constitution,  269 
Psychoses,  circumscribed,  107 

periodical,  123 

prison,  109,  270 

symptomatic,  250 
Psj'chotherapy,  45 
Puerperal  psychoses,  206 

mania,  206 

Race-preservation,  10 
Reaction,  type  of,  16 
Reality  motive,  9 
Reasoning,  4 
Reflex,  light,  134 

consensual,  135 

sympathetic,  135 
Repression,  9 
Retardation,  73 
Retrospective  delusions,  94 

falsification  of  memory,  94 

Sadism,  273 
Schizophrenia,  156 
Schnauzkrampf,  172 
Seizures,  paretic,  138 
Self-preservation,  10 
Senile  confusion,  200 


INDEX. 


345 


Senile  delirium,  201 
deterioration,  200 
paranoid  states,  201 

Senile  psychoses,  196 
causes,  197 
symptomatology,  197 
course,  202 
prognosis,  202 
diagnosis,  202 
involution,  198 
pathology,  204 
treatment,  205 

Senium  precox,  197 

Sensation,  definition  of,  2 

Sensorium,  2 

Sentiments,  definition  of,  6 

Sexual  inversion,  273 
perversion,  273 

"  Shell-shock,"  272 

Simulation,  271 

Somatopsychoses,  66 

Speech,  tests  of,  301 

Stabschenzellen,  149 

Stereotypy,  75,  173 

Stupor,  TJ 

catatonic,  171 
depressive,  123 

Sublimation,  21 

Suggestibility,  ^(i,  156 

Sulfonal,  44 

Swindlers,  270 

Symbolism,  83 

Symptomatic  psychoses,  250 


Syphilis,  246 

Syphilitic  psychoses,  246 

Temperament,  definition  of,  6 
Thinking,  2 

definition  of,  4 

difficulty  of,  yz 

tests  of,  313 
Thought,  content  of,  161 

deprivation,  163 

dilapidation  of,  162 

looseness  of  train  of,  168 

paralysis  of,  74 
Thyroigenous  psychoses,  251 
Toxic  psychoses,  216 
Traumatism,  248 
Treatment,  40 
Trional,  44 
Tumor,  245 

Unconscious,  9 
Uremia,  250 

Verbigeration,  75,  173 
Veronal,  44 
Volition,  2 

definition  of,  S 

disorders  of,  74 

Wahnsinn,  107 
Wet-brain,  233 
Witselsucht,  246 
Word  salad,  162,  170 


B 


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